Final answer:
A coder can use the history of malignant neoplasm (category Z85) if the cancer is in remission and there is no ongoing treatment for it. This is important for accurately documenting the patient's medical history after successful cancer treatment.
Step-by-step explanation:
Yes, a coder can use the history of malignant neoplasm (category Z85) if cancer is no longer present and no current treatment is directed at the site. This category is applicable to individuals who have had a malignancy and it has been eradicated or resolved, and they are not undergoing any current treatment specifically for cancer. It is important to properly document the patient’s cancer history, which includes not only the staging of the cancer at the time of diagnosis but also the treatment and current status of the disease.
Staging plays a critical role in understanding a patient’s cancer condition. For instance, localized cancer is confined to the place of origin without spread, while regional cancer has spread to nearby lymph nodes or tissues. The history code accurately reflects that the past condition of cancer does not currently hold active disease status.