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Posted By Mary Peabody on 04-30-2020, 16:53:36 in Ob-Gyn
Hello Melanie,

Thank you for your assistance with my questions. You are so valuable and I really appreciate you. If a patient is 2+ years since completion of treatment for endometrial cancer and she is being seen by the physician for surveillance visits, the original surgery was TLH and then chemo, no longer undergoing treatment. Would you report Z85.42 history of endometrial cancer for the DX for the surveillance visit or Z08 Encounter for follow up examination?


· -  She is 2+ years since completion of treatment in Feb 2020. For now we continue to recommend surveillance, next exam in 4 months.
· Pelvic exams and review of symptoms now every 6 months until she is 5 years out then annually. Routine PAP smears are not typically recommended as part of surveillance.
· CA-125 is a sensitive marker for this patient. We plan to repeat in 3 months prior to next visit.  
Comments (1)
Posted By Melanie Witt on 05-01-2020, 11:32:56
Thanks for the kind words. I do love what I do. Per ICD10 guidelines you would report Z08 first followed by Z85.42
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