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Oncology & Hematology Coding Alert

Reader Questions:

Hold On to 'History of' Code in This Case

Published on Tue Jul 27, 2010

Question:A patient had been free of her breast cancer for two years and receiving no treatment, but documentation for her recent follow-up appointment shows discovery of metastasis to the lymph nodes. Does the metastasis mean I need to include the code for the primary breast cancer rather than a history-of code?Kansas SubscriberAnswer:No. Because documentation shows the primary malignancy is no longer present, you should report a "history of" code.Straight from the source: ICD-9 official guidelines instruct: "When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy."The guidelines also state that you should code metastasis to another site as a secondary malignant neoplasm to that site. So [...]
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