tci Part B Insider - 2010 Issue 32

Reader Questions: If Cancer's Still Present, Ignore 'History of' Codes

Question: At what point should I report a "history of" code instead of the actual cancer diagnosis?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 medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring."...

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