Coding Secondary Diagnoses

When performing inpatient quality reviews, DRG quality is generally excellent.  But when tracking and trending issues, most will notice that the highest level of errors fall within the coding of secondary diagnoses. 

Secondary diagnoses are very important to capture.  In many cases they affect reimbursement.  Even if a code doesn’t affect reimbursement in a MS-DRG system, it is possible that it does in an APR-DRG system.  And regardless of the payment related issues, secondary diagnosis are important to facilities for other reasons such as internal data comparison, state data submission and comparison, grant availability and physician statistics to name a few.

As such a review of the coding guidance for reporting additional diagnosis is provided.  Refer to Section III, below, for the Official Coding Guidelines and further details of what coders should be aware of when capturing coded data.

Section III. Reporting Additional Diagnoses

GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES 

For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: 

            -          clinical evaluation; or

            -          therapeutic treatment; or

            -          diagnostic procedures; or

            -          extended length of hospital stay; or

            -          increased nursing care and/or monitoring.

The UHDDS item #11-b defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded." UHDDS definitions apply to inpatients in acute care, short- term, long term care and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

Since that time the application of the UHDDS definitions has been expanded to include all nonoutpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc).

The following guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-9-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider.

A. Previous conditions

If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.

However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

B. Abnormal findings 

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider. 

C. Uncertain Diagnosis

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals. 

As evident by the above guidelines, the UHDDS gives coders a clear definition of what is required in coding secondary diagnosis.  However, many facilities will ask a coder to add other secondary diagnosis that fall outside the definition of secondary diagnoses as listed above.  Note that in Section A, the UHDDS does allow for facilities to add to the list of previous conditions (secondary diagnoses) if it is in a hospital policy.  Coders should make sure they have those policies in writing.

Reference:  ICD-9-CM Official Guidelines for Coding and Reporting, Effective 10/1/2011

Steroid Induced Hyperglycemia vs Steroid Induced Diabetes

In 2008, ICD-9-CM added a new category for secondary diabetes and its associated manifestations.  One of the more common code assignments from this category is the one to reflect steroid induced diabetes mellitus.  This article will discuss both steroid induced diabetes and transient hyperglycemia; and correct code assignment for each disease process.

Glucocorticosteroids are used to treat swelling and inflammation in a number of disease processes.  The more commonly used corticosteroids are dexamethasone, solumedrol,  and prednisone.  Some of the disease processes treated with steroids include chronic obstructive pulmonary diseases (emphysema, asthma, bronchitis), cerebral edema caused by trauma or tumors,  autoimmune disorders such as lupus, and irritable bowel syndrome.  Steroids are also used to decrease the probability of rejection of transplanted organs.  Typically these patients are on a constant low-dose; but in situations where the disease acutely exacerbates, the patient may receive high-dose intravenous infusions of these medications to counteract the acute process.   It is not uncommon in these situations for blood glucose levels to rise in both diabetic and non-diabetic patients.

Glucocorticosteroids are considered “stress hormones”.  When these steroids are released or infused in abundance into the body, the drugs decrease inflammation or swelling  and cause excess glucose to be released from the liver and inhibit absorption of the glucose by muscles.  This in turn causes blood glucose levels to be elevated because the pancreas cannot produce enough short-term insulin to counteract the large amount of glucose in the blood stream.   In most cases, once the high-dose corticosteroids are decreased or discontinued, the blood glucose normalizes.  If the blood glucose remains elevated, then further testing may occur to rule out the presence of an underlying diagnosis of diabetes mellitus type I or II, or secondary diabetes.   According to the National Institute of Diabetes and Digestive and Kidney Disease, only 1-2% of all diabetes cases can truly be classified as secondary diabetes.  Actual steroid induced diabetes results when the cells in the pancreas that release insulin are either inhibited or destroyed due to these medications.    More commonly, patients are predisposed to diabetes mellitus based on things such as family history or obesity.  And the use of steroids exacerbates the condition, prompting further work-up.

From a coding standpoint, physician documentation is the key.  Many patients who have steroid-induced hyperglycemia may be treated with sliding scale insulin or oral hypoglycemics because it is important to control blood glucose levels even in those patients who do not have a formal diagnosis of diabetes mellitus.  However, this temporary treatment of hyperglycemia does not automatically constitute a diagnosis of diabetes.  In many cases, the physician will document “hyperglycemia due to steroids”, and should be reported using the codes 790.29 and E932.0.  When utilizing an encoder, extreme care should be taken to choose the correct descriptors.  For instance, typing “hyperglycemia” in an encoder may lead to the option to choose “steroid induced diabetes” which results in the incorrect code assignments of 249.00 and E932.0.  Unless the physician has clearly stated the patient has steroid induced diabetes, the coder cannot assume the presence of hyperglycemia equals diabetes, and should only assign the appropriate codes based on the physician’s clinical judgement and documentation.

REFERENCES:

Coding Clinic 4^th Q 2008 p 91

Http://www.NIH.gov, “Prevalence and Incidence of Secondary and Other Types of Diabetes”, Om P. Gupta, MD

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Coding Gastric Varices with Alcoholic Cirrhosis

 The coding rules for gastric varices are unique and worth discussing in more detail. 

 Coding rules direct coders for mandatory multiple coding of underlying disease process and the manifestation associated with that disease entity.  Dual classifications require assigning the underlying condition as first listed followed by the manifestation as secondary. 

 As stated in Section 1, Subsection A, #6 of the Official ICD-9-CM Guidelines for Coding and Reporting “Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.  For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.”  The key point to this rule is the multi-body systems’ manifestations that can occur.  For this reason the underlying condition is coded first. 

 The ICD-9-CM code book guides the coder when referencing the underlying condition by the phrase “use additional code”.  Referencing the tabular listing of the manifestation code will also direct the coder to “code first underlying condition.  As per Coding Guidelines, “These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.”  The coder can also see the correct code sequence within the index; both codes will be sequenced with the etiology code first followed by the manifestation within brackets. 

 Examples include diabetic neuropathy, certain retinopathies, endocarditis with other diseases, and esophageal varices with cirrhosis or portal hypertension. 

 Manifestation codes cannot be designated as the principal diagnosis, thereby leading the coder to sequence the underlying condition as primary – except in a few situations - such as coding gastric varices with alcoholic cirrhosis. 

 For those clinical presentations of a patient with gastric varices caused by alcoholic cirrhosis – the coding convention described above does not apply.  Here with this exception to the coding rule, the coder must be aware that coding of the manifestation is sequenced as primary while the alcoholic cirrhosis will be coded as secondary. 

Injections, Infusions, and Hydration

Often times coders need to review the specific coding guidelines for reporting injections, infusions, and hydration.  Certainly, these codes have been revised many times over the past few years and if coders do not stay abreast of these, they will be in a position of high scrutiny.

Many facilities require coders to not only code for these types of procedures, but to also assign the charge code for them.  It is important to know the intricate differences in the code application.  These codes can be assigned in various outpatient settings, so it is important to also understand the various resources incurred.

Resources

APC coding allows for appropriate reimbursement for the specific resources utilized.  APCs are the government’s method of paying for facility outpatient services by the Medicare program as delineated through the Outpatient Prospective Payment System (OPPS.)

Resources include nursing staff, supplies, technical overhead, and time to perform procedures. Ancillary orders carried out by nursing staff or other departments include obtaining specimens for laboratory tests; transporting patients for EKGs; performing x-rays and other special studies such as CT scans, ultrasounds, echocardiograms, sonograms, stress tests, and VQ Scans.  Some examples of nursing procedures include intravenous, subcutaneous, intra-muscular and PO medications; IV fluid administration, heplocks, catheter placements, foley catheters, and NG tube placements. 

Resource utilization or consumption is reflected in the E/M level. Supplies are separately billed.  Nursing procedures and other ancillary procedures are separately coded and reimbursed.  Specifically, the focus of this article is to discuss injections, infusions, and hydration.  The codes for chemotherapy administration are not  explicitly addressed.

Documentation in General

Drug Administration must be ordered by a physician or other party who is licensed to diagnose and treat.

Each substance administered must be clearly documented:

• No abbreviations
• Route and site easily distinguished
• Start and stop times for each substance
• Amount of each substance given
• Substance(s) administered

Some services included in drug administration codes are not reported separately with CPT codes:

• Use of local anesthesia
• IV start
• Access to indwelling IV, subcutaneous catheter or port
• Flush at conclusion of infusion
• Standard tubing, syringes and supplies

Documentation - Timed

• Start & Stop times are necessary to distinguish if the drug administered is initial, sequential, additional, and current.
  • Hospitals may report infusions that are started outside and continued in the Emergency Department provided the start and stop times are properly documented.
• If the time is 15 minutes or less, report the procedure using an IV push injection code.
• Therapeutic Infusions
  • Initial or first hour of infusion is from 16 to 90 minutes.
• Hydration Infusions
  • Initial or first hour of infusion is >30 minutes and <91minutes

NOTE:  If there is no stop time for hydration, no code can be reported.

• Additional hours of infusion
  • Report add-on codes for additional hours of infusion (beyond the first hour) only after more than 30 minutes have passed from the end of the previously billed hour (91 minutes allow an additional hour to be charged)

Initial Service and Hierarchy

Follow the rule of hierarchy when selecting the initial service for procedures coded in a facility, with the top services listed below being primary to those below:

• Chemo Infusion
• Chemo Injection
• Non-chemo Therapeutic infusions
• Non-chemo Therapeutic injections (IVPs)
• Hydration

When multiple modes of drug administration are provided, only one “initial” service code should be reported. Two “initial” codes may be listed when two separate IV sites are used (e.g., right forearm and left forearm).

Hydration

96360 – Intravenous infusion, hydration; initial, 31 minutes to 1 hour.

Do not report IV infusions for hydration of 30 minutes or less.

96361 – Intravenous infusion, hydration; each additional hour

This is an add on code.

Report 96361 for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments.

NOTE:  Codes 96360-96361 are intended to report a hydration to consist of a pre-packed fluid and electrolytes (e.g., normal saline, D5-1/2 normal saline +30mgEq KCl/liter), but are not used to report infusion of drugs or other substances. When fluids are used to administer the drugs, the administration of the fluid is considered incidental hydration and is not separately reportable.

Infusions

96365 – IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366 – IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour

This is an add on code.  List separately in addition to code for primary procedure.

Report 96366 in conjunction with 96365 or 96367.

Code 96366 for infusion intervals of greater than 30 minutes beyond 1 hour increments.

96367 – IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour

This is an add on code.  List separately in addition to code for primary procedure.

Code 96367 in conjunction with 96365, 96374, 96409, 96413 if provided as a secondary or subsequent service, after a different initial service is administer through the same IV access.

Code 96367 only once per sequential infusion of the same infusate mix.

96368 – IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion

This is an add on code.  List separately in addition to code for primary procedure.

Code 96368 only once per encounter.

96369 –Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).

For infusions of 15 minutes or less, use 96372

96370 – Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour

This is an add on code.  List separately in addition to code for primary procedure.

Code 96370 in conjunction with 96369

Code 96370 for infusion intervals of greater than 30 minutes beyond 1 hour increments

96371 – Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s).

This is an add on code.  List separately in addition to code for primary procedure.

Code 96371 in conjunction with 96369.

Code 96369, 96371 only once per encounter

Injections

96372 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96372 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial

Injections – IV Push

NOTE:  These are not time based codes.

96374 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

96375 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential IV push of a new substance/drug

This is an add on code.  List separately in addition to code for primary procedure.

Code 96375 to identify IV push of a new substance/drug if provided as a secondary substance/drug after a different initial service is administered through the same IV access

96376 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential IV push of the same substance/drug provided in a facility.

This is an add on code.  List separately in addition to code for primary procedure.

Do no report 96376 for an IV push performed within 30 minutes of a reported IV push of the same substance or drug.

Code 96376 is reported by facilities only.

96379 –Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion.

Reference: AMA CPT Manual

Welcome to the May issue of Maxim Coding CornerSM! As a leader in the HIM industry, Maxim Health Information Services is committed to providing you with coding-related topics that matter to you. This month, we are focusing on Coding Sepsis, Severe Sepsis, and Septic Shock. Read on below to learn more.

Coding Sepsis, Severe Sepsis, and Septic Shock

Assigning appropriate diagnostic codes for sepsis is often difficult, especially when physician documentation is vague, incomplete, or conflicting. Physicians tend to use the terms bacteremia, urosepsis, and sepsis interchangeably in a chart, leaving the coder the task of deciphering the meaning.

The Official Guidelines for Coding and Reporting has an entire section devoted to understanding all of these terms, their definitions, correct coding, and sequencing. There are actually two types of SIRS (Systemic Inflammatory Response Syndromes), defined as infectious and traumatic.

When assigning codes for a diagnosis of sepsis (SIRS due to infection), a minimum of two codes will be used. The first code is always the underlying cause followed by a code from the 995.9 subcategory. In this subcategory, the coder must define whether the sepsis is without acute organ dysfunction (995.91) or with acute organ dysfunction (995.92). When coding 995.92, the documentation must support that the organ dysfunction is clearly due to the sepsis and not due to another underlying medical condition. In those cases, the coder must also assign codes for the acute organ dysfunction (for example, acute kidney injury or acute respiratory failure) per the "use additional code" notes. If the physician documents septic shock, 995.92 is always sequenced first, followed by the code 785.52.

There are also instances in which the physician may document SIRS in relationship to trauma or to a non-infectious inflammatory response. The coding and sequencing guidelines are generally the same as for an infectious cause, in that the underlying event is sequenced first, followed by the appropriate code to reflect SIRS due to noninfectious process either with or without acute organ dysfunction, codes 995.93 or 993.94, respectively. Some examples of non-infectious processes are severe trauma, burns, pancreatitis, malignant neoplasms, and even heat stroke. More in-depth information can be found in Section I.C.17.g of the ICD-9-CM Official Guidelines for Coding and Reporting.

When determining whether or not the SIRS is due to an infectious or non-infectious cause, keep in mind that if the non-infectious cause leads to an infectious process or cause such as bacterial sepsis (e.g., a severe burn becoming infected), the coder would assign the SIRS from the "infectious" choices.

Coding sepsis/SIRS can be less confusing when following three small steps; (1) underlying cause (2) SIRS type (3) with or without organ dysfunction. However, when in doubt about the documentation, query the physician for clarification because the coder cannot assume the physician means sepsis when either bacteremia or urosepsis are documented. These are non-specific terms and have specific codes of their own. Therefore, any conflicts or ambiguity in physician documentation needs to be resolved before the appropriate diagnostic codes can be assigned.

Reference
Official ICD-9-CM Guidelines for Coding and Reporting

Welcome to the January issue of Maxim Coding CornerSM! As a leader in the HIM industry, Maxim Health Information Services is committed to providing you with coding-related topics that matter to you. This month, we are focusing on New Endovascular Revascularization CPT Codes for the Peripheral Arteries of the Leg. Read on below to learn more.

New Endovascular Revascularization CPT Codes for the Peripheral Arteries of the Leg

As coders, we all know that January 1st not only begins a new year, but it also brings changes to CPT codes. 2011, of course, was no different. This year, CPT added a whole new section of endovascular revascularization (open or percutaneous, transcatheter) procedures of the lower extremity (37220-37235).

As with most endovascular procedures, these codes also include the work of accessing and selectively catheterizing the vessel, crossing the lesion, radiological supervision and interpretation directly related to the interventions performed, embolic protection if used, closure of the arteriotomy by any method, and imaging performed to document completion of the intervention in addition to the interventions performed. Where these codes differ from other endovascular procedure codes is that they describe endovascular procedures performed percutaneously and/or through an open surgical exposure of the vessel. Included in this set of codes are balloon angioplasty, atherectomy, and stenting. Balloon angioplasty is always included in this family of codes (37220-37235) when performed.

These codes describe revascularization procedures for three arterial vascular territories of the lower extremity: iliac, femoral/popliteal, and tibial/peroneal. The iliac territory has three vessels in it including the common iliac, internal iliac, and external iliac. The femoral/popliteal territory in one lower extremity is considered a single vessel in CPT specifically for the endovascular lower extremity revascularization codes 37224-37227. The tibial/peroneal territory is also divided into three vessels to include the anterior tibial, posterior tibial, and peroneal arteries.

There are specific coding guidelines for each of the three vascular territories. In both the Iliac and tibial/peroneal territories there is one primary code used for the initial artery treated. The primary codes are 37220 or 37221 for the iliac and 37228, 37229, 37230, or 37231 for the tibial/peroneal arteries. These can be followed by up to two add on codes which include 37222, 37223 for the iliac territory, and 37232-37235 for the tibial/peroneal territories because these territories have three vessels that could potentially be treated.

For the femoral/popliteal territory, a single interventional code is used. Only one code is reported when two lesions are treated in this territory due to CPT considering this to be one vessel. Report the most complex procedure performed for this territory (e.g., use 37227 if a stent is placed for one lesion and an atherectomy is performed on a second lesion in this territory).

Add on codes in this section are used for different vessels, not different lesions in the same vessel. If more than one stent is inserted in the same vessel this is only coded/reported once. If a lesion crosses into two arteries but can be treated with one therapy it should be reported with one code even though two arteries are treated. The example in the CPT book explains that if the stenosis extends from the common iliac artery into the proximal external iliac artery and a single stent is placed to open this entire lesion, this should be coded as a single stent placement in the iliac artery (37221) even though two vessels are treated. It is with a single therapy, therefore only coded once. If therapy is required for bifurcation lesions that require treatment of two distinct arteries in the iliac or tibial/peroneal territories, a primary and add on code would be used to describe this intervention. When the same territories of both legs are treated during the same session, modifiers may be required to help describe the procedures performed.

It may be necessary to perform mechanical thrombectomies or thrombolysis to assist in restoring blood flow to the area of occlusive disease and this would be reported separately in addition to any other interventions that were performed.

Reference
Association, A. M. (2010). CPT 2011 Professional Edition. In CPT 2011 Professional Edition (p. 208-210). Chicago: American Medical Association. 

Welcome to the December issue of Maxim Coding CornerSM! As a leader in the HIM industry, Maxim Health Information Services is committed to providing you with coding-related topics that matter to you. This month, we are focusing on Selection of Principal Diagnosis and Sequencing When Coding Neoplasms. Read on below to learn more.

Selection of Principal Diagnosis and Sequencing When Coding Neoplasms

One of the challenges that coders face is determining the principal diagnosis and proper sequencing of neoplasms. Coders need to be aware of specific ICD-9-CM coding and sequencing guidelines to ensure that patient encounters are grouped under the proper MS-DRGs.

Primary Malignancy
If treatment is directed to the primary site, sequence that as the principal diagnosis or primary diagnosis unless the encounter or hospital admission is solely for the purpose of radiotherapy, chemotherapy, or immunotherapy.

Specific Therapies
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign code V58.0 for radiation therapy, V58.11 for chemotherapy, or V58.12 for immunotherapy as the first listed or principal diagnosis.

Secondary Sites
When a patient is admitted having 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.

Anemia
When the admission or encounter is for management of anemia associated with malignancy, and the treatment is only for the anemia, assign the code for the anemia as the principal diagnosis followed by a code for the malignancy. If anemia in neoplastic disease and anemia due to anti-neoplastic chemotherapy are clearly documented in the medical record, both codes 285.22 and 285.3 can be assigned.

When the admission or encounter is for the management of anemia due to chemotherapy, immunotherapy, or radiation therapy and the only treatment is for the anemia, the anemia is sequenced first. The neoplasm code is assigned as an additional code along with the appropriate E code to identify the adverse reaction.

Dehydration
When the admission or encounter is for the management of dehydration due to a malignancy or therapy received or a combination of both and only the dehydration is being treated, the dehydration is sequenced first, followed by a code for the malignancy.

Surgery
When the admission or encounter involves the surgical removal of a neoplasm followed by adjunct chemotherapy or radiation therapy during the same episode of care, the neoplasm code should be assigned as the principal diagnosis.

Surgical Complication
When the admission or encounter is for the treatment of a complication resulting from a surgical procedure, designate the complication as the principal diagnosis if treatment is directed at resolving the complication.

Personal History
When the primary malignancy has been previously excised or eradicated from its site and there is no 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 the primary malignancy. Any mention of extension, invasion, or metastasis to a nearby structure or organ or to a distant site that is being treated is coded as a secondary malignant neoplasm to that site and may be the principal diagnosis in the absence of the primary site.

Follow Up
When a follow-up examination is conducted to determine if there is any evidence of recurring or metastasizing cancers and no evidence of malignancy is found, the case is classified to the V67 category, using the appropriate subdigit to identify the most recent mode of therapy carried out. For example:
V67.0X Surgery only
V67.1 Radiation therapy only or radiation therapy following surgery
V67.2 Chemotherapy only or chemotherapy following surgery or radiation

The secondary diagnostic code would represent the history of malignancy (for example, code V10.51, previous history of bladder malignancy). Be sure to code the diagnostic procedure carried out, such as a cystoscopy or biopsy. If the follow-up examination reveals recurrence or metastasis, category code V67 would not be used. Instead, the appropriate code for the primary site (recurrence) or for the metastatic site of malignancy would be assigned.

References
ICD-9 Official Guidelines for Coding and Reporting
AHA Coding Clinic for ICD-9-CM, July/August 1985, Volume 2, Number 4, page 16
AHA Coding Clinic for ICD-9-CM, July/August 1985, Volume 2, Number 4, page 16