If there is no further treatment directed to a previously excised primary malignancy, how should the encounter be coded?

When a primary malignancy has been excised and there is no further treatment or active management directed at it, the proper coding guideline requires the use of Z85, which indicates a personal history of malignant neoplasm. This is important for documenting that the patient has a past history of cancer, even if they are currently considered free of the disease.

Using Z85 allows healthcare providers to capture essential patient history that can be relevant for future treatments, screenings, or for assessing risk factors in subsequent healthcare decisions. By coding it this way, it also avoids any confusion about the status of the malignancy, as it clearly indicates that the original malignancy has been resolved without ongoing treatment or recurrence.

Other choices do not accurately reflect the coding guidelines since using the primary malignancy code or coding it as a current condition would imply active disease, which is not the case if there is no further directed treatment. Choosing not to code at all would omit important clinical information regarding the patient's medical history.