ICD-10 Coding for Personal History of Colon Cancer(Z85.038)
Complete ICD-10-CM coding and documentation guide for Personal History of Colon Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Personal History of Colon Cancer
Z85.03Primary Range
Personal history of malignant neoplasm of colon
This range is used to code for patients with a history of colon cancer that is no longer active but requires ongoing surveillance.
Personal history of colonic polyps
Used for patients with a history of colonic polyps, often coded alongside Z85.03 when both conditions are relevant.
Family history of malignant neoplasm of digestive organs
Used to indicate a family history of gastrointestinal cancers, which may influence surveillance strategies.
Key Information: ICD-10 code for personal history of colon cancer
Essential facts and insights about Personal History of Colon Cancer
Primary ICD-10-CM Code for personal history of colon cancer
Decision Criteria
clinical Criteria
- Patient has completed treatment and is under surveillance.
documentation Criteria
- Records show no active treatment or evidence of disease.
Applicable To
- History of colon cancer
Excludes
- Current colon cancer (C18.x)
Clinical Validation Requirements
- No evidence of active disease
- Completed curative treatment
- Surveillance colonoscopy results
Code-Specific Risks
- Incorrectly coding active cancer instead of history
Coding Notes
- Ensure documentation clearly states the cancer is in remission and surveillance is ongoing.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Personal History of Colon Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.038.
Impact
Clinical: Potential mismanagement of patient care., Regulatory: Non-compliance with documentation standards., Financial: Denial of claims due to insufficient documentation.
Mitigation Strategy
Use specific phrases like 'status post resection with no evidence of disease'., Include dates and treatment details.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Verify treatment completion and absence of active disease.
Impact
Using active cancer codes for patients in remission.
Mitigation Strategy
Regular training on coding guidelines and documentation review.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Personal History of Colon Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Personal History of Colon Cancer
Use these documentation templates to ensure complete and accurate documentation for Personal History of Colon Cancer. These templates include all required elements for proper coding and billing.
Surveillance Colonoscopy
Specialty: GastroenterologyRequired Elements
- Date of original diagnosis
- Treatment completion date
- Current surveillance plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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