Active breast cancer diagnosis versus History of Breast Cancer

Good afternoon-

I am in a discussion with some of our lead physicians in regard to HCC/RAF scoring. There seems to be a discrepancy regarding patients who were diagnosed with breast cancer, and are s/p mastectomy. There is no active chemo or radiation therapy currently; however, the patient is still on Tamoxifen therapy. The oncologist believes the diagnosis should be coded as active (C-code in ICD10) while the gynecologist believes it should be history of (z code in ICD10). Understanding how Medicare Advantage plans are using HCCs as a predictive method for future health costs, one code gives an RAF value while the other one doesn't. And they are submitting conflicting codes to the same payer under the same tax id. I would appreciate any feedback, comments, source references, etc. I find it quite interesting, and not being a working clinician I don't want to get in the middle of a clinical "discussion" without having some references to cite.

Thanks for any insight you may provide,

Donna

Donna M. Beaulieu, CRC, C-CDIS, CPC-I, CPMA, CPC, CEMC, CEDC, CFPC, CCP-P, CRP
Assistant Director, Patient Financial Services

[Emory Healthcare]


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