Barbara Posted Thu 25th of February, 2010 18:43:25 PM
Can someone tell me when you start to use "personal history of" breast cancer, colon cancer, etc.
SuperCoder Answered Fri 26th of February, 2010 05:40:01 AM
There are two types of history V codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. The exceptions to this general rule are category V14, Personal history of allergy to medicinal agents, and subcategory V15.0, Allergy, other than to medicinal agents. A person who has had an allergic episode to a substance or food in the past should always be considered allergic to the substance.
Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.
Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
Barbara Posted Fri 26th of February, 2010 11:30:23 AM
I am told that you can use the dx of breast cancer (or any cancer) up to a year after
treatment instead of using the Personal Hx of. Is this correct and if it is who sets the
guidelines for this?
Thanks in Advance.
SuperCoder Answered Fri 26th of February, 2010 13:22:54 PM
If the breast cancer is still present and treatment is still going on then you can use the Dx of breast cancer. But if there are supporting documents and path which confirms that there is no sign of cancer then only you can use the history of Breast cancer or any other.
If there is absence of any cancer after treatment, then you can also use the history of breast cancer if the patient comes for an annual breast screening/well women exam or something related with breast.
All ICD related guidelines are decided by CMS and the CDC/National Center for Health Statistics.