Z85.3 can be billed as a primary diagnosis if that is the reason for the visit, but follow up after completed treatment for cancer should coded as Z08 as the primary diagnosis.If Patient is only going to dr for 6 mth (or 2, 3, 4, 5, 7, 8 year, etc) follow up because they had cancer previously, has finished actively treating Dx, what can I bill with? Z85.3 is not a primary dx code and can't be billed in primary position on 1500. At a loss....
If you have a MMG or other imaging showing no active malignancy how could you continue coding for an "active" breast cancer? Tamoxifen would be considered prophylactic treatment to prevent recurrence of malignancy at that point. Ethically the physician should be coding C50._ for five years if the patient is considered in remission.Personal History DX Codes
If the patient is not being actively treated and the cancer or urinary stones etc...have been resected/treated it would not be clinically backed by coding an active cancer/stone without evidence of the disease being present. Once the cancer/stone has been excised or destroyed and is no longer being actively treated it is coded to a history code. For example, if a patient is taking Tamoxifen for breast CA then they are still to be coded with the breast CA diagnosis code as they are still being actively treated. Once the treatment is completed and the patient is deemed to be in remission then the HX of breast CA would be coded.
Hope this helps further clarify
M.Hannus, CPC, CPMA, CRC