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Coding: Your Top Coding Concerns Solved

Coding: Your Top Coding Concerns Solved

What is the appropriate diagnosis code for a patient being “followed” for a previous cancer when there is no known residual malignancy? It doesn’t really make sense to code for the cancer since it doesn’t exist, really, but cancer is still the reason for the visit.

And when should the diagnosis code cease to be reported as a “neoplasm” and begin to be reported as “history of a malignant neoplasm of XXX”?

That’s just the start of the mystery.

One article from a Medicare carrier Web site suggests the use of V-codes for patients who have no known residual tumor but are receiving medically necessary follow-up care because of a past malignancy. But do they mean the V-code as in “history of” or the b-type version of a V-code that requires there is “treatment being provided”?

The instructions from the ICD-9-CM Official Guidelines for Coding and Reporting, page 24, seem clear at first:

“When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.”

But what about when there is no further treatment directed at that site but there is some evidence of disease? What if there were margins present when the neoplasm was excised? What if a PSA indicates some cells are present, even if the number is extremely low?

Is there not a version of physician management that consists of watchful waiting, review-of-systems questions for years, and increased frequency of diagnostic testing directed at potential recurrence or activity?

There is not real clarity to any of these issues; we’d love to hear how you handle them. In the meantime, here are cancer-related issues that are clear.

Coding right for cancer

Cancers with documentation stated as “History of XXX cancer on current adjuvant therapy or other active treatments” should be coded as active cancer. For example, a patient with history of breast cancer on adjuvant therapy should be coded as active breast cancer 174.9D.

Active cancer may be reported for a patient with cancer who is not receiving active treatment, but may be receiving treatment for symptoms. For example, a patient with brain cancer receiving hospice care is coded as active cancer 191.9B.

Use personal history (V-codes) when:

  • There is no evidence of any existing primary malignancy

  • The primary malignancy has been excised or eradicated


  • There is no adjuvant treatment, chemotherapy, or radiotherapy directed to that site


  • There is no evidence of recurrence of the primary malignancy

If the documentation states there is “no evidence of disease,” use a personal history code or V-code.

Here’s an example: A patient had breast cancer 10 years ago and had a radical mastectomy. She is no longer receiving any treatment and the documentation indicates that there is no evidence of disease. Report a personal history of breast cancer: V10.3A.

Use “family history of neoplasm” for patients without cancer but with a family history of cancer. You can also use this term for preventive Tamoxifen trials in high-risk women. When in doubt, contact your carriers or payers directly. You don’t want to code for cancer that, in retrospect, a payer decides did not exist.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 18 years. He can be reached via editor@physicianspractice.com.

This article originally appeared in the November 2008 issue of Physicians Practice.

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