tci Part B Insider - 2013 Issue 36

Reader Question

Question: We treated a patient for leukemia several years ago and now we see her annually for a yearly visit. Should we continue to report the leukemia diagnosis or switch to a “history of” cancer code? Answer: If the patient’s treatment is completed, the medical record reflects no instances of recurrence, and the physician documents no sign of reoccurrence, using a “history of” diagnosis would be appropriate if it bears on and is relevant to the patient’s treatment. ICD-9 coding guidelines specify that the personal “history of” codes “explain a patient’s past...

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