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History codes vs. actual disease

  1. Question History codes vs. actual disease
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    Is there a time frame for using history v-codes as opposed to using the actual diagnosis code?

    Patient had colon cancer (no date given), but has had re check colonoscopy on a 1 year f/u. Still being seen by Sloan Kettering too, active care

    Should I use colon cancer coding or history?

  2. #2
    A patient is always coded as having active cancer if they are still being treated for it. If the colon was resected and is now NED and is not receiving any further radiation/chemo/or other drugs, I would code history of.

  3. #3
    International Member

    As per ICD Coding Guidelines,

    1. Personal Hx codes explain a patient' past medical condition that no longer exits & is not receiving any treatment, but that has the potential for recurrence, therefore may requrie continued monitoring.

    2. When a primary malignancy has been previously excised or eradicated from its site & there is no further treatment directed to that site & there is no evidence of any existing primary malignancy, a code from category V10, Personal Hx of malig. neo., should be use indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as secondary malgn. neo. to that site. And the secondary site may be the principal or 1st listed wit hthe V10 code used as a secondary code.

    So, if patient still receiving care for Colon Cancer then 153 code is appropriate & if Colonoscopy is done for any other reason then V10 will be correct one.

    Hope this helps!!!


  4. #4
    Default E &M with scope
    So fi the CA is no longer present but the patient returns yearly for check for scope to look would you be able to bill the E&M as well since over time the medical hx, family hx meds could of changed??

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