Wiki "History of" vs Current cancer dx

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jdibble

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A patient was taken to the OR for a split-thickness skin graft for a wound resulting from the excision of a squamous cell cancer. Diagnosis listed on OP report is "Status post excision of a squamous cell cancer". Surgery was coded with V58.41 Enocunter for planned post-op wound closure and V10.83 for History of the skin cancer. The Plastic Surgeon questioned why this was not coded with the cancer code - 173.7 since she says this is part of the care of the cancer, even though she stated it as staus post and the cancer was excised.

Can someone advise me if this should have been coded with the cancer code or if it would be the history since it is stated as status post. Also any information on how to determine when the cancer is to be coded as current or with the history code would be greatly appreciated - especially in this circumstance as this doctor needs concrete proof for everything that is done. :rolleyes:

Thanks,
 
when you are treating the cancer, then it is current. You only code history of when all treatment has been completed and the patient has not had any reoccurence. You are still treating the cancer in the above senario, so you would code as current cancer, not a history of.
 
The skin graft is treating the defect created by an excision, it is not treating the cancer. In that it is in no way a threapeutic measue to treat the cancer. If there is no plan for further treatment and the physician has documented no evidence of disease then it is hx of. However the primary dx should be for an aquired deformity of the skin, with the cancer as either hx of or active as a seconday dx.
 
mitchellde said:
The skin graft is treating the defect created by an excision, it is not treating the cancer. In that it is in no way a threapeutic measue to treat the cancer. If there is no plan for further treatment and the physician has documented no evidence of disease then it is hx of. However the primary dx should be for an aquired deformity of the skin, with the cancer as either hx of or active as a seconday dx.
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Thanks Debra for your response. However my question now is what do you mean by the primary dx should be for an "aquired deformity of the skin". I'm not sure what dx I would use then rather than the V58.41 which was used. Can you point me in the right direction?

Thanks again for your help!
 
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