The coding guidelines for cancer state that “When the primary malignancy has been excised, no further treatment is directed to the site & there is no evidence of an existing malignancy,” the clinician must document ‘history of XYZ cancer’ and not the cancer diagnosis.
Full Answer
What are the coding guidelines for cancer?
The coding guidelines for cancer state that “When the primary malignancy has been excised, no further treatment is directed to the site & there is no evidence of an existing malignancy,” the clinician must document ‘history of XYZ cancer’ and not the cancer diagnosis.
When should a patient be assigned a current active cancer code?
A patient should NEVER be assigned a current, active cancer code if the disease is no longer being treated. Assigning cancer codes: Example: Patient is being seen for an adenoma of the pituitary gland.
What is an example of a cancer code assignment?
Assigning cancer codes: Example: Patient is being seen for an adenoma of the pituitary gland. Below is the correct code assignment for this patient’s condition
How should cancer information be coded on a claim?
Documentation in the medical record and information sent in on a claim must match. If cancer is clearly documented in the medical record it should also be coded on the claim and vice versa. Also, if there is a secondary cancer (metastasis) clearly documented in the medical record it should be coded on the claim as well.
Where are the Official guidelines for Coding and Reporting published?
Guidance for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). This guidance is to be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website.
What is the coding convention for coding current cancer and a history of cancer?
Current: Cancer is coded as current if the record clearly states active treatment is for the purpose of curing or palliating cancer, or states cancer is present but unresponsive to treatment; the current treatment plan is observation or watchful waiting; or the patient refused treatment.
When do you code cancer?
Code C80. 1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy.
What is the guideline on coding impending and threatened conditions?
Code any condition described at the time of discharge as "impending" or "threatened" as follows: First, review the medical record to determine if the impending or threatened condition culminated in actual occurrence. If it did occur, code as confirmed diagnosis.
Do you code cancer first?
When coding malignant neoplasms, there are several coding guidelines we must follow: To properly code a malignant neoplasm, the coder must first determine from the documentation if the neoplasm is a primary malignancy or a metastatic (secondary) malignancy stemming from a primary cancer.
What is the ICD-10 code for chemotherapy?
1 for Encounter for antineoplastic chemotherapy and immunotherapy is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
Which of the following is the most important factor in coding?
Basic CodingQuestionAnswerWhich of the following is the most important factor in codingaccuracy of codesWhich of the following is a coding system used to document the procedure for suturing a lacerationCurrent procedural terminology (CPT)22 more rows
What is considered active treatment for cancer?
Treatment given to cure the cancer, such as chemotherapy or radiation therapy. This does not include long-term treatment such as hormone medication, which may be taken for several years to maintain remission.
What is considered active treatment?
Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.
What is the purpose of the ICD-10-CM official coding guidelines?
These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.
What is the meaning of provider in the ICD-10-CM guidelines?
Rationale: Per ICD-10-CM guidelines, the term provider means a physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.
When there is a code first note and an underlying condition is present the condition should be sequenced first?
When there is a "Code first" note and an underlying condition is present the: -instructional note (Code first) should be followed. -underlying condition should be sequenced first. -coder can determine which code to sequence first.
What is the code for bone marrow leukemia?
Code all leukemias except myeloid sarcoma (M-9930/3) to C42.1 (bone marrow). Myeloid sarcoma is coded to the stated site of origin.
When to use topography code?
Use the topography code provided when a topographic site is not stated in the diagnosis. This topography code should be disregarded if the tumor is known to arise at another site.
What is the difference between a pathologist and a cancer registrar?
In the use of the behavior code, pathologists are usually interested in "specimen coding" whereas the cancer registrar's main interest is identification of the primary tumor.
When to use numerically higher code number?
When no single code includes all diagnostic terms , use the numerically higher code number if the diagnosis of a single tumor includes two modifying adjectives with different code numbers.
When to use subcategory 8?
Use subcategory ".8" when a tumor overlaps the boundaries of two or more categories or subcategories and its point of origin cannot be determined.
When coding malignant neoplasms, there are several coding guidelines we must follow?
When coding malignant neoplasms, there are several coding guidelines we must follow:#N#To properly code a malign ant neoplasm, the coder must first determine from the documentation if the neoplasm is a primary malignancy or a metastatic (secondary) malignancy stemming from a primary cancer.
What is the code for primary cancer?
If the site of the primary cancer is not documented, the coder will assign a code for the metastasis first, followed by C80.1 malignant (primary) neoplasm, unspecified. For example, if the patient was being treated for metastatic bone cancer, but the primary malignancy site is not documented, assign C79.51, C80.1.
What is a history code for cancer?
When a current cancer is no longer receiving treatment of any kind, it is coded as a history code. For instance, the patient had breast cancer (C50.xx) and underwent a mastectomy, followed by chemoradiation. The provider documents that the patient has no evidence of disease (NED).
What is the code for metastatic cancer?
If the documentation states the cancer is a metastatic cancer, but does not state the site of the metastasis, the coder will assign a code for the primary cancer, followed by code C79.9 secondary malignant neoplasm of unspecified site.
What is the ICd 10 code for cancer?
For more context, consider the meanings of “current” and “history of” (ICD-10-CM Official Guidelines for Coding and Reporting; Mayo Clinic; Medline Plus, National Cancer Institute):#N#Current: Cancer is coded as current if the record clearly states active treatment is for the purpose of curing or palliating cancer, or states cancer is present but unresponsive to treatment; the current treatment plan is observation or watchful waiting; or the patient refused treatment.#N#In Remission: The National Cancer Institute defines in remission as: “A decrease in or disappearance of signs or symptoms of cancer. Partial remission, some but not all signs and symptoms of cancer have disappeared. Complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body.”#N#Some providers say that aromatase inhibitors and tamoxifen therapy are applied during complete remission of invasive breast cancer to prevent the invasive cancer from recurring or distant metastasis. The cancer still may be in the body.#N#In remission generally is coded as current, as long as there is no contradictory information elsewhere in the record.#N#History of Cancer: The record describes cancer as historical or “history of” and/or the record states the current status of cancer is “cancer free,” “no evidence of disease,” “NED,” or any other language that indicates cancer is not current.#N#According to the National Cancer Institute, for breast cancer, the five-year survival rate for non-metastatic cancer is 80 percent. The thought is, if after five years the cancer isn’t back, the patient is “cancer free” (although cancer can reoccur after five years, it’s less likely). As coders, it’s important to follow the documentation as stated in the record. Don’t go by assumptions or averages.
What is the ICd 10 code for primary malignancy?
According to the ICD-10 guidelines, (Section I.C.2.m):#N#When a primary malignancy has been excised but further treatment, such as additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is complete.#N#When a primary malignancy has been excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.#N#Section I.C.21.8 explains that when using a history code, such as Z85, we also must use Z08 Encounter for follow-up examination after completed treatment for a malignant neoplasm. This follow-up code implies the condition is no longer being actively treated and no longer exists. The guidelines state:#N#Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment.#N#A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code.#N#For example, a patient had colon cancer and is status post-surgery/chemo/radiation. The patient chart notes, “no evidence of disease” (NED). This is reported with follow-up code Z08, first, and history code Z85.038 Personal history of other malignant neoplasm of large intestine, second. The cancer has been removed and the patient’s treatment is finished.
What is a follow up code?
This follow-up code implies the condition is no longer being actively treated and no longer exists. The guidelines state: Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. A follow-up code may be used to explain multiple visits.
Does history of cancer affect relative value units?
The fear is, history of will be seen as a less important diagnosis, which may affect relative value units . Providers argue that history of cancer follow-up visits require meaningful review, examinations, and discussions with the patients, plus significant screening and watching to see if the cancer returns.
Can neoplasms be active?
Some neoplasms may not be active but remain at a cellular level, and can become active.
Is cancer history?
History of Cancer: The record describes cancer as historical or “history of” and/or the record states the current status of cancer is “cancer free,” “no evidence of disease,” “NED,” or any other language that indicates cancer is not current. According to the National Cancer Institute, for breast cancer, the five-year survival rate ...
Do providers look at cancer at the cellular level?
According to a presentation by James M. Taylor, MD, CPC, providers look at cancer at a cellular level; whereas, coding guidelines look more at the organ level. In his opinion, common concerns among providers are: Some neoplasms may not be active but remain at a cellular level, and can become active.
Why are tumor codes ordered in a hierarchy?
The codes are ordered in a hierarchy so that increasing numbers generally indicate increasing degrees of tumor involvement. For each field, code the highest applicable number. Exception: Codes for Unknown and Not Applicable are a lower priority over codes with lower numbers.
What should be coded from the scheme for the site the clinician considers most likely to be the primary?
Cases not microscopically confirmed should be coded from the scheme for the site the clinician considers most likely to be the primary.
What is clinical information used for in coding CS?
Clinical information may be used in coding CS fields, minimizing the use of coding "unknown", instead coding "none" for regional lymph nodes or distant metastases . This applies primarily to localized or early (T1, T2) stage in the TNM system. This applies to situations where there is no reason to doubt that the tumor is local, based on the clinical information available. By coding regional lymph nodes as negative and/or coding distant metastasis as none rather than coding these fields as unknown, the CS computer algorithms will derive a stage group that includes the best information available.
What is coding based on?
Coding is based on the best available clinical and pathologic information.
What is the code for death certificate?
Death Certificate Only cases are usually coded as either unknown (9,99,999), or not applicable (8,88,888) in all CS fields.
When the patient does not receive pre-operative therapy (that is systemic chemotherapy, hormone, immunotherapy, and radiation?
When the patient does not receive pre-operative therapy (that is systemic chemotherapy, hormone, immunotherapy, and radiation therapy), and the operative/pathology report information disproves the clinical information, code the operative/pathology information.
When does collaborative staging apply?
Collaborative Staging System applies to cases diagnosed on or after January 1, 2004. Collaborative Stage is not used for cases diagnosed prior to January 1, 2004.