How Long Should a Cancer Dx Code be Used?

March 17th, 2015 - Seth Canterbury, CPC, ACS-E/M

Question: Is there a set year span for billing Breast Cancer vs. History of Breast Cancer? I am told it is 5 years but I am not sure…
 
 
Answer: Per the ICD-9-CM Official Guidelines for Coding and Reporting:
 
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.
 
A doctor may still choose to say a patient "has" breast cancer for 5 years after the cancer was removed, but coders do not defer to this medical concept of whether a person keeps this label. We must instead go by the official coding concept of whether a person still has cancer, as outlined in the guidelines above.
 
This issue has caused many physicians grief because of the fact that it is still medically necessary to monitor patients who've had certain types of cancers for several years after the neoplasm was excised or eradicated. Proper coding conventions, as quoted above, instruct that a "Personal Hx of..." V-code be used if no further treatment is being given and there is no evidence remaining of the cancer, but some payers will reject payment for visits if this "Personal Hx of..." V-code is the only code used. Several providers have gotten around this by continuing to use the active neoplasm code. This is the easy and dirty solution that achieves the reimbursement they feel is fair for a medically necessary service, but this practice is not correct according to the ICD-9-CM instruction quoted above.
 
The right way to fix this issue would be to either 1) convince the authors of the ICD-9-CM and ICD-10-CM Official Guidelines (CMS and the National Center for Health Statistics) to alter their instructions to allow for the coding of certain neoplasms as "active" for a certain amount of time after the neoplasm itself was excised/eradicated, or 2) get all of the payers who deny f/u visits billed w/ "Personal Hx of..." V-codes alone to change their policies and recognize these as medically necessary services when billed in relatively close proximity (within a few years) to the excision/eradication. Since both of these correct solutions would be a long and uphill battle, it is understandable why, but still not excusable that, many choose the easy and dirty, but technically wrong and non-compliant solution.

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