Wiki history of vs current

[cansas]

I am having claims failing medical necessity. The patient's primary malignancy was removed. The patient is receiving treatment for the mets which is indicated because of the histology. My docs argue that it is not considered history of, but coding guidelines state it is hx of when excised or removed. Since it "recurred" elsewhere in the body they feel it is not history of.

Any thoughts?

 

[mitchellde]

If the primary site is no longer being treated then it is history of. But your provider is correct that it is the same neoplasm located in another location . This is demonstrated by the use of the mets code and the history of code for the primary site. There are no codes for history of the mets since it is known that the mets is an extension of the primary

 

[BlakeCarswell82]

"Treatment" for coding purposes consists of chemotherapy for primary site, radiation to primary site, or medication directed at primary site. Otherwise, it is a history. A doctor's version of history is different than a coder's version of history. A doctor will probably say that there is still a primary malignancy for up to five years, whether there is treatment or not.

 

[cansas]

Thanks for the help. Our issue is that our FI denies if using the hx of on the primary cancer. It would be easier if coding guidelines matched clinical thinking. We end up having to appeal quite a bit.

 

[Tonyj]

Thanks for the help. Our issue is that our FI denies if using the hx of on the primary cancer. It would be easier if coding guidelines matched clinical thinking. We end up having to appeal quite a bit.

Are you using "hx of" as the primary diagnosis? The primary dx would be the reason for the visit which appears to be the treatment of the mets. Curious to know why they would deny.

I also agree with Debra. The mets is an extension of the primary Ca therefore I'd still code it as active unless the physician states there's no evidence of disease and no ongoing treatment to the primary site.

 

[cansas]

We are coding the mets as primary and the hx of as secondary. The med the provider is ordering meets NCCN guidelines to treat the mets based on the primary site, but the med does not meet medical necessity if the primary cancer is hx of. We didn't have this problem until we changed FI's to CGS.