Wiki Pfsh

[alices]

good morning everyone, I just was curious on how others code/not code, we were told from an auditor that if in the PFSH they have Hx Cancer and we don't know if it is current being treated or just Hx then we were not to code it (is that so?).. how do any one else handle this situation? thanks for all the help..alice

 

[jmcpolin]

I would probably code first the reason why they were there in the ED and then maybe history of cancer second.

 

[Traci Watson]

If the note states patient has history of cancer I would give credit for past medical history.

 

[TonyaMichelle]

The personal Hx V10 codes for malignant neoplasm are only coded when the condition no longer exists and is not receiving any treatment, but has the potential for recurrence, and therefore may require continued monitoring.

 

[alices]

re-pfsh

Good morning, thank you for answering, I do count it towards my E/M ,but what I am asking (and asked wrong sorry for that ) is example pfsh hx cervical ca, pt comes in for vomiting and dr's final dx gastroenteritis would you code the ca as an additional dx and use a v code or code as if they have it or not code it at all?
or another example again pt has pfsh cervical ca and pt comes in with abd pain final dx abd pain and they refer the pt to come back for a xray/ct (this is er pt's).. for me I don't code the hx ca if I don't know if it is current or has been tx, unless like the 2nd scenerio for abd pain I would send it back to get clarification on the Cancer, but I have other coders here that are sending it back to the doctor everytime they see in hx cancer whether it pertains to their visit or not, so I just want to code right so any and all help is truly appreciated..alice

 

[TonyaMichelle]

Personal hx codes explain a patient's past medical history that no longer exists and is not receiving any treatment, but has the potential for recurrence, and therefore may require continued monitoring.

History codes are also accepatable on any medical record regardless of the reason for the visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.

So, I would use code V10.41 Personal history of malignant neoplasm of Cervix uteri as an additional code to the primary reason for the visit.

 

[FTessaBartels]

NO, I would not code it

If the only time the Hx of cancer is mentioned is in the PFSH or ROS section, then NO, I would not code it.

I would code it ONLY if it were specifically stated in the assessment/plan area / diagnosis section.

I would VERY careful about this if you are using an EHR becasue they frequently repopulate everything, whether or not it was addressed. (I recently saw one of my own office visit records with "epitaxis" as a diagnosis .... last time I had a nose bleed was over a year ago and this visit had nothing to do with that issue).

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[TonyaMichelle]

hx codes

The coder who captured the code for epitaxis to your current visit for a totally different reason was absolutely wrong because "epitaxis" would not be a past Hx code, however, if you had any past medical histories indicated in the V-code section of ICD-9 for example, "Personal Hx of alcoholism(V11.3) followed by "Past Hx of chemical dependency"(305.90),and "Personal Hx of manic-depressive psychosis"(V11.1), and you just happen to come to your physician's office complaining of severe pain, your primary physician would most likely think twice before giving you any narcotic pain relievers and send you to a pain management specialist based on your past medical history. For those reasons, past medical history is a very important component to help the physician with his medical decision making for your current illness. Another example, if a patient has a past medical Hx of seizures, with that knowledge, the physician would know what type of medication that he should not prescribe for that patient that may trigger siezures.

 

[alices]

re-pfsh

Thank you everyone for your help it is appreciated..alice