I am new to coding oncology and could use some help.
Can coders code from PMH? This visit talks about the cancer spreading, but the PMH indicates bone, the impression just says multiple sites without a comment from the current doctor. Would the PMH hold more weight than the impression? The doctor?s problem list for this date of service has multiple sites. When it isn?t clear would the coder query the doctor or code from PMH, impression, what is listed in the HPI (if something is documented) or Doc?s current visit problem list?
Reason for visit: Prostate cancer
HPI: talks about upper back pain
PMH: Prostate Infection ? 2 weeks ago
Malignant prostate metastatic to bone
Prostate cancer
Impression
Patient Active Problem List
Diagnosis
Date Noted
? BPH (benign prostatic hyperplasia) 4/26/2015
Priority: High
? Prostate cancer metastatic to multiple sites 04/22/2015
Priority: High
Overview Note:
WITH T6 CORD COMPRESSION -- patient started on CASODEX 50 mg po daily 4/23/2015
S/p RT TO THE SPINE - LAST ON 5/6/2015 (3000 cGy)
LUPRON PLANNED
ZOMETA - GIVEN 4/24/2015
HOSPITALIZATIONS:
4/19/2015 - 4/27/2015 - DIAGNOSIS / SPINAL CORD COMPRESSION
5/4 - 5/6/2015 - PAIN CONTROL / HYPOTENSION
? COPD (chronic obstructive pulmonary disease)
04/19/2015
? Thoracic compression fracture
04/19/2015
?Intractable back pain
04/19/2015
? AAA (abdominal aortic aneurysm) infrarenal - 5.3 cm
04/19/2015
Patient otherwise stable except for SEVERE BACK PAIN - oxycodone helps for 3-4 hours.
__________________________________________________ ___________
PLAN
ZOMETA and LUPRON TODAY
MS CONTIN 15 mg po qhs - if insufficent, may increase to 30 mg po qhs
PAIN MGMT CONSULT (ANESTHESIA) - consider epidural injection / pump
F/u 2 weeks.
Problem List as of 5/29/2015
ICD-9-CM
Noted - Resolved
COPD (chronic obstructive pulmonary disease) 496
4/19/2015 - Present
Thoracic compression fracture
805.2
4/19/2015 - Present
Intractable back pain 724.5
4/19/2015 - Present
RESOLVED: Mass of thoracic vertebra 733.90
4/19/2015 - 5/15/2015
AAA (abdominal aortic aneurysm) infrarenal - 5.3 cm 441.4
4/19/2015 - Present
RESOLVED: Hyponatremia 276.1
4/19/2015 - 5/15/2015
RESOLVED: Pain management V57.89
4/19/2015 - 5/15/2015
Prostate cancer metastatic to multiple sites
185
199.0
4/22/2015 - Present
Coding unclear metastatic cancer
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