Wiki History of Colon Cancer

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letiflynn

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I am reviewing a rejected claim from Humana that says the dx code is incorrect.
This is what the chart reads:


Past Medical History:
Diagnosed with colon cancer summer 2011, followed at ***Hospital.

Problem 1: Colon Cancer (153.9)
She is followed 2 times weekly by Dr. She received chemotherapy, now is being mointored for recurrence.


As you can see, it is not very specific. I am not sure what the proper dx code would be here. I am an extern here, so any and all help would be very much appreciated! :)
 
My suggestion would be to verify if patient has infact had a relapse, which is what I would be lead to believe with the frequesncy of the visits. Also, Humana may not like the .9 (unspecified) so a more specific DX of which part of the colon may be helpful.

Heather O'Leary, CPC, CHONC
 
It's possible that Humana is looking for a "history of" code, which you would use if the cancer no longer exists. V10.05 Personal history of malignant neoplasm of large intestine. History of is implied because they are monitoring for recurrence and do not state that, in fact, the cancer has recurred. You can't assume it has recurred based on the frequency of the visits. It would be wise to query the physician regarding the status of the malignancy.

I would also contact Humana and find out why they think the dx code is not correct.

PS- Working denied claims is excellent experience to gain during an externship. You can learn so much doing this task! You also bring a lot of value to your extern site because you have the potential to recoup quite a lot of money for them.
 
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Thank you all for your responses. I am unable to consult with the physician. My supervisor asked that I do my best in figuring out what is wrong. This is a very large clinic (400+ employees) with no coders! I am relying heavily on my instructor and my peers on AAPC for help.

I'm going to go with the "history of" code. I agree with you, lorrpb. The part where it states she is being monitored for recurrence makes me believe I should use the V code. I am going to be sure to inform my supervisor that due to lack of clarity it was difficult to figure out.

Thank you again!!
 
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