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Leah Posted Tue 16th of June, 2015 11:46:00 AM

Hello,
Will you please advise on the proper coding for patients with metastatic disease? Should both cancers always be coded for at a patient's visit pertaining to either? For example, if a patient was coming in for prostate cancer with bone mets, but only the prostate portion was addressed at his visit, should bone mets still be coded? Any insight to the proper coding would be greatly appreciated.
Thank you,
Leah
CPC, CUC

SuperCoder Answered Wed 17th of June, 2015 01:14:55 AM

When the primary malignancy has been previously excised or eradicated from its site and there is not adjunct treatment directed to that site and no evidence of any remaining malignancy at the primary site, use the appropriate code from the V10 series to indicate the former site of primary malignancy. Any mention of extension, invasion, or metastasis to a nearby structure or organ or to a distant site is coded as a secondary malignant neoplasm to that site and may be the principal diagnosis in the absence of the primary site.

When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

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