Wiki recurrent cancer

[JTE79]

Per Dr note.....A 79-year-old female with a history of stage IIIC, ovarian papillary serous carcinoma diagnosed in 2012 status post TAH/BSO debulking in 2012 and received carbo/Taxol x6 with Taxotere substituted the last 2 cycles. She did well until September 2014, when she developed a vaginal apex recurrence and subsequently received additional carboplatin and liposomal doxorubicin in 4 cycles and 2 additional cycles of carboplatin alone reportedly with complete clinical response after her last cycle in February. She reports 3 weeks of bleeding and was found to have additional recurrent disease in the vaginal apex, which has been biopsied. She is seeing us in consultation regarding radiation treatment options.
Vaginal recurrence of ovarian cancer.

?... Is this coded as mets or is this coded as ovary. Since the site is now the vagina not the ovaries. Note does state history of...and does not state mets.
Ovary=183.0 or 198.82 vaginal mets with HX of ovary Vaginal recurrence of ovarian cancer.10.43

 

[M.pennyoNeill]

Ob CA ? mets to vagina

Jennifer: I would certainly use this as additional education to the provider that he/she needs to "Paint the Picture" within his note. It sounds like mets to me but remember we are not allowed to assume as coders. It must be documented. Certaining use the hx of ovarian ca and it indicate even vaginal ca from 2012 as history However, she is now presenting with recurrance and seeking treatment so you are back to an active treatment of ca and not the hx code. This is certainly a wonderful opportunity to querry the provider explaining he needs to be a specific as possible in this area. Needs to call what it is, do not assume.