mattstella101
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A lot of our physicians will mention a certain type of cancer (without using the word history) and document that the patient is just following up with oncology. They seem to be using current cancer codes because they do not realize that history codes exist. Is it okay to use current (cancer) codes based on that documentation even though when I look at surgery and oncology notes I see that it has been removed and chemo was done? I know I shouldn't be coding based on other clinics but for the most part the physicians rarely use the word "history." Please help thanks!