Oncology & Hematology Coding Alert

Question:

Kansas Subscriber

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 you should report the secondary neoplasm appropriate for the documented site, such as 196.3 (Secondary and unspecified malignant neoplasm of lymph nodes; lymph nodes of axilla and upper limb). For the primary malignancy which is no longer present, report V10.3 (Personal history of malignant neoplasm; breast).