What should a coder do if a patient has a history of malignant neoplasm and no current diagnosis?

When a patient has a history of malignant neoplasm and there is no current diagnosis, the appropriate step for a coder is to use the Z85 code, which signifies a personal history of malignant neoplasm. This is important because Z codes are specifically designed to indicate a history of previous conditions that do not currently have active status. By utilizing the Z85 code, the coder accurately captures the patient's medical history while also providing necessary information for any future treatment or follow-up.

Using a history code is crucial for various reasons, including proper patient management, ensuring that healthcare providers are aware of the patient’s past conditions, and supporting any necessary surveillance for potential recurrences. This approach aligns with coding guidelines that emphasize the importance of accurately representing a patient’s medical history.