Wiki Personal history vs current

Create Wiki
C

cansas

Guest
Messages
35
Location
Marietta, Ohio
Best answers
0
I have a patient that is on taxotere. Patient had breast cancer over a decade ago. Now has mets to bone, lung liver. The LCD from my FI does not allow for a history of breast cancer code to support giving this treatment. I do truly feel the mets should be primary and the hx of breast cancer as secondary, but that doesn't jive with the LCD.

The provider wants the dx to be current breast ca, so that it is covered.

Do I just wait for the appeal and submit with nccn guidelines?
 
Unfortunately your provider signed a contract with the carrier probably, that they will be HIPAA compliant and those rules state we are to follow correct coding guidelines with the ICD-9, HCPCS and CPT books to include all payer guidelines (LCD). He will need to select a different drug and inform the patient as to why.

You must use the correct diagnosis codes of 198.5 Bone, secondary as primary and V10.3 (personal history of breast)
 
The patient is still receiving Taxotere which is active treatmernt for Breast Cancer therefore the Breast cancer is coded as active. Remember as long as you are treating the cancer with active treatment it is coded as active cancer.
So Code first the one being treated, If this a visit for the Taxotere you code the V58.11 code first then breast cancer (174.9) with the bone, lung and liver mets last,
 
This is for Medicare? CMS allows for several compendia to support medical necessity including NCCN. Per NCCN guidelines, V10.3 (Hx of breast cancer) supports the use of Taxotere for recurrent or metastatic disease. Your medicare contractor must honor CMS requirements.

I would code it according to the guidelines (V10.3 plus the mets diagnoses) and fight your contractor if they deny it.

It should be covered.

The recurrence is not in the breast, so I would not code 174.*.
 
alannae said:
This is for Medicare? CMS allows for several compendia to support medical necessity including NCCN. Per NCCN guidelines, V10.3 (Hx of breast cancer) supports the use of Taxotere for recurrent or metastatic disease. Your medicare contractor must honor CMS requirements.

I would code it according to the guidelines (V10.3 plus the mets diagnoses) and fight your contractor if they deny it.

It should be covered.

The recurrence is not in the breast, so I would not code 174.*.
Click to expand...

The patient is on Taxotere which is a treatment for active breast cancer , the guideline is as long as you are treating the cancer with active treatment , you code the cancer as active
 
Another patient, similar scenario. Primary bronchogenic which was treated. Patient has mets to bone. The physician considers this a recurrence of bronchogenic cancer to the bone and feels the bronchogenic is now current and not history because it is the same cancer, just a different site.

Thoughts?
 
While your provider logic is correct the primary site of the lung is history at that site if there is no evidence of disease and no treatment to the lung. Using the combination of the mets and the history of the lung indicates that the bone mets is due to the lung which is the primary site no longer requiring treatment.
 
You must log in or register to reply here.
Top