Personal History Codes

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When is it correct to use a personal history of cancer code? Or even personal history of urinary stones?
 

pscanlan

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To describe the nature of the presenting illness, it may be necessary to name previously treated diseases.

Take as an example a colectomy. In this procedure, we're removing part or all of the patient's colon. The patient may currently have colon polyps or malignant growths in their colon, or they may not. If they've been previously removed, a history code is appropriate. So z85.00 or Z86.010 could be used to describe the reason for surgery, either alone or in combination with other codes. Probably not on their own though. It's hard to make a fully formed example from scratch. Let me try again.

Another reason to use history codes are for colonoscopies. If the patient (z86.010) or the patient's family (Z83.71) has a history of colon polyps or malignant neoplasms, then that can justify doing a colonoscopy. In this case, in the absence of any new findings, the history code would be the primary diagnosis on the claim.

So the above are reasons to use history codes as a primary diagnosis. There are a whole host of reasons to use them as secondary diagnoses. For anesthesia (which I code currently) the ASA physical status modifier indicating the relative health of the patient needs to be supported by additional diagnoses. A colonoscopy on a healthy patient might be P1 and need no support. A colectomy on a patient with systemic disease might be P3 or P4 and need additional diagnosis codes (like history codes) to detail the extent of the systemic disease. If you (as a provider) are claiming that your surgery was more complex or detailed than normal, you'll generally have to justify that by detailing the diseases or conditions that you had to account for. A common few I see are Z95.1, Z95.0 and Z98.84. If these apply to your patient and you are seeing them for anything other than a yearly checkup, odds are the doc had to account for the existing conditions before recommending new medication or treatment options. It would be appropriate to add any history codes that could affect treatment options.

Hope this helps.
 
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Personal History DX Codes

Hello,

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
 

mjstack

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re: HX of Breast Cancer dx

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....
 

thomas7331

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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....
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.
 
Last edited:

juliedale

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Personal History DX Codes

Hello,

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
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.
 

lkcums

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Hello

I want to add an additional question to this. My team and I are having a bear of a time to wrap our head around Cancer coding (active vs. history of). What are some examples of documentation considered to be active treatment (to code as still active)? Are there any websites out there to help us understand what active treatment is (drugs? Therapies?). We have been told by Auditors about Adjuvant therapy (still trying to figure this out). Also we are have been told on seperate occaisions that patient taking Tamoxifen is coded as active and then to code it as history of.
Thanks everyone in advance.
 

csperoni

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Over the years, I have heard very differing opinions from even reliable resources. I have heard once the surgery is done and the cancer is removed to use history for surveillance exams. I have also heard to use the cancer dx for 5 years, because it's not considered in remission yet. I think those are 2 extremes and I fall in between.
In the official guidelines Chapter 2, section d:
"When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed diagnosis with the Z85 code used as a secondary code."
So, it depends on how you define no further treatment. In our office, we use that to mean only NO type of any further treatment, and use the active cancer codes until then. So a patient on Tamoxifen, I would definitely code as active, not history.
 
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