General Surgery Coding Alert

Question: Could you please provide some direction about when I should use "history of" codes instead of the actual cancer diagnosis code?

Virginia Subscriber

Answer: You should use a "history of" diagnosis when the patient's treatment is complete and the surgeon states that there is no sign of reoccurrence. For instance, use V10.3 (Personal history of malignant neoplasm; Breast) for a patient with prior history of breast cancer.

Follow guidelines: The ICD-9-CM 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."

You should report the condition using a cancer diagnosis code (such as 174.8, Malignant neoplasm of other specified sites of female breast) if the patient is still receiving active treatment. Even if the surgeon states that he was able to completely remove the tumor with clear margins, you should still use the cancer code if the patient is receiving any treatment directed at that cancer.

For example: If a patient will undergo chemotherapy and radiation therapy after mastectomy, continue to use the cancer code (174.8) for any follow-ups. Even if there are no signs of recurrence, you should not switch to the personal history codes until all active treatment concludes.

Watch for long term: Active treatment might involve long-term medication such as Tamoxifen. If a patient began breast cancer treatment five years ago but is still taking Tamoxifen, you should code breast cancer as current using a code such as 174.x (Malignant neoplasm of female breast).