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Hx of VS active disease

  1. #1
    Default Hx of VS active disease
    Medical Coding Books
    I recently had a conversation with one of our physicians about coding the encounter when it is felt that the patients active disease, CA of pharynx turns to HX of pharyngeal CA.
    She coded and encounter for hx of on one date of service as the reason for the encounter and then two months later, coded it as active CA.
    I explained to her that she is the only one that can determine if the cancer has indeed been eradicated. She wants guidelines....any advice or links? Thanks, all!

  2. #2
    Default Hx versus active disease
    According to ICD-9 coding guidelines you would use an active diagnosis code for any disease or cancer that is currently being treated. Once the cancer is no longer being actively treated you would change to the history diagnosis code. You can find information regarding this in the front of the ICD-9 book, in coding guidelines, Chapter 18, section 4 (History of). Hope this helps!
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

  3. #3

  4. #4
    To add to A. Dimmit's wonderful explanation, please be aware that screenings to evaluate the status of an inactive cancer does NOT constitute active treatment. If chemo/meds/etc. have been discontinued and there is no evidence of disease (NED), you must code "history of" regardless of ongoing semi-annual or annual screenings. I audit claims for an MA and the most common errors I find are for a screening s/p 5 years mastectomy or TURP, etc. with NED, no meds, no tx. For some reason, the physician's office is still billing a current cancer. Dangerous (from the reimbursement prospective) error!

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