Coding corner: Using a ‘history of cancer’ code vs. ‘active cancer’ code

Selecting the diagnosis code that best captures a patient’s condition at the time of his or her visit can be a challenge, but keeping some basic guidelines in mind helps. And to ensure best coding practices, providers can always refer to ICD-10-CM guidelines.

Here’s what you need to know about coding for cancer.

The documentation should always clearly indicate one of the following:

• The cancer is active and still being treated.
• The cancer is no longer active or is in remission and there’s no recurrence; i.e., no further treatment is necessary.

When coding for active malignancy versus coding for a person with a history of malignancy, ICD-10-CM coding guidelines are specific. Section I.C.2.m. states:

“When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

“When a primary malignancy has been previously 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.”

Forms of active treatment include:

• Current hormonal therapy for the cancer or neoplasm (not for prophylactic purposes)
• Watchful waiting or active surveillance, meaning the malignant neoplasm has not been treated but is being closely monitored for progression
• A patient has a condition but isn’t being treated because he or she refuses treatment or is too frail

An exception to these rules occurs when coding multiple myeloma and leukemia. For these diagnoses, there are “in remission” codes that providers should use once treatment is completed and the patient achieves remission.

The following scenarios help differentiate between situations where providers should use “history of malignancy” codes and those in which the malignancy should be coded as active.

Scenario one:
A patient with a history of breast cancer who had chemotherapy, radiation and a mastectomy — and who currently has no evidence of recurrence — comes in for an office visit. The provider documents that the patient isn’t receiving active therapy for breast cancer. The code for personal history of malignant neoplasm of the breast (Z85.3) should be used.

Scenario two:
A female patient who was diagnosed with cancer of the central portion of the right breast returns to the office for a visit after a mastectomy and is currently receiving radiation therapy. Doctors should document current active treatment (radiation), and use a code for active breast cancer; e.g., C50.111 malignant neoplasm of central portion of right female breast.

Scenario three:
A patient who was diagnosed with cancer of the axillary tail of the left breast three years ago — and who had a mastectomy followed by radiation and chemotherapy — comes in for an office visit. She is currently taking Arimidex^® and undergoing adjuvant therapy, which is considered active treatment. Therefore, it’s inappropriate to use a “history of breast cancer” code. Providers should use active cancer codes for as long as the patient is still undergoing adjuvant therapy.

Scenario four:
A patient who was diagnosed with acute myeloblastic leukemia was treated with chemotherapy and successfully achieved remission. He returns to the office for a visit and has no evidence of recurrence. The code for acute myeloblastic leukemia in remission (C92.01) should be used.

In summary

• Clinical evidence needs to be documented to support an active cancer code. The documentation must clearly indicate that the cancer was either not treated or is being actively treated, including with adjuvant therapy.
• If the cancer has been eradicated and there’s no evidence of recurrence and no further treatment is needed, then it’s appropriate to use a “personal history of cancer” code.
• Multiple myeloma and leukemia have “in remission” codes that providers should use when a patient achieves remission following treatment.

 None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Also, keep in mind that ICD-10-CM diagnosis codes and ICD-10-CM Official Guidelines for Coding and Reporting are subject to change. It’s the responsibility of the provider to ensure that current ICD-10-CM diagnosis codes and the current ICD-10-CM Official Coding Guidelines for Coding and Reporting are reviewed prior to the submission of claims.