Jenneta Posted Fri 02nd of October, 2015 14:17:02 PM
Pt came in today for follow up of Radiation Therapy to the Prostate (ICD9 185). Patient no longer has prostate cancer. What diagnosis codes should I use? Should I be using history codes which would be Z08-Follow-up examination after treatment of malignant neoplasm and Z85.46-History of prostate cancer ? Or should I use C61-prostate cancer?
SuperCoder Answered Sat 03rd of October, 2015 14:43:45 PM
Thanks for your question. You should use the personal history of code Z85.46, Personal history of malignant neoplasm of prostate. According to the guidelines, a personal history code is used when there is a past medical condition that no longer exists, the patient is no longer receiving any treatment, but that has the potential for reoccurrence and therefore may require continued monitoring. Hope this helps.
Jenneta Posted Mon 05th of October, 2015 10:08:15 AM
Good morning. Thank you. Should I be using the Z08-Follow up Examination after treatment? If not, when should I use this code?
SuperCoder Answered Wed 07th of October, 2015 10:56:08 AM
Yes, Z08; Encounter for follow-up examination after completed treatment for malignant neoplasm is used for medical surveillance following completed treatment. You would use an additional code to identify the personal history of malignant neoplasm.