Coding corner update: Improve medical record documentation for cancer in remission

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next few issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

It’s important to properly document the status of cancer in the medical record to support the ICD-10-CM diagnosis code selected. Cancer should be documented as active cancer, as personal history of cancer or cancer in remission. Incorrectly coding a cancer diagnosis can be problematic for a patient in the future.

Definitions of each cancer status:

• Active cancer: Cancer that is currently being treated. Various methods could include surgery, radiation, chemotherapy, drugs, alternative medicine or a combination of the various methods.

• Personal history of cancer: Cancer that has been excised or eradicated from its site. No further treatment of the malignancy is being directed at the site and there’s no evidence of any existing cancer.

• Cancer in remission: Cancer that has been removed; however, there may be cells that are still present but are currently undetectable. There are two kinds of remission: complete remissionand partial remission.

Active cancer status
The following is an example of coding for active cancer that’s currently being treated by the doctor:

The patient has active lung cancer. His or her doctor discusses the treatments available, explains the risks and possible outcomes, and answers any questions the patient has regarding the diagnosis. If the patient decides to start treatment immediately, the doctor documents the assessment as C34.11 — Malignant neoplasm of upper lobe, right bronchus or lung, as the diagnosis. The plan is the patient will begin chemotherapy in a week, with follow up as needed.

In instances such as this, where cancer has been diagnosed and is documented as currently receiving treatment, it should be coded using a current neoplasm code (C00-D49) from the “Neoplasms” chapter.

Personal history of cancer status
When a patient has a personal history of cancer, and the cancer is no longer active and doesn’t need treatment, the doctor needs to specify that using the proper code.

For example, if a patient was diagnosed with prostate cancer five years ago and there’s no current treatment being directed at the prostate cancer, the doctor should use Z code Z85.46 – Personal history of malignant neoplasm prostate. This indicates that the patient has a personal history of prostate cancer and it’s no longer an active cancer that needs treatment directed towards it.

Z-codes can be found in the “Factors Influencing Health Status and Contact with Health Service (Z00-Z99)” section of the ICD-10-CM manual.

In most cases, doctors will still monitor the condition for a certain period of time due to the nature of the cancer. However, it’s incorrect to use an active cancer code (C00-D49) in cases where the doctor has indicated that there’s no evidence of the existing cancer and no treatment is being directed towards the site of the primary malignancy.

Remission status
There are two types of remission:

• Complete remission: There are no signs and symptoms that indicate the presence of cancer.

• Partial remission: A large percentage of the signs and symptoms of cancer are gone, but some still remain.

According to the American Cancer Society, to qualify for either type of remission, the reduction in the size of the tumor must last for at least one month. When a person is in remission, there may be microscopic cancer cells that are unable to be identified by the current techniques and technologies available.

Complete remission is better because there’s a higher rate of recurrence with a partial remission. A person in remission, whether complete or partial, may experience a recurrence of cancer at some point in the future.

ICD-10-CM codes C90-C95 Multiple myeloma and malignant plasma cell neoplasms and Leukemia (multiple types) include remission codes which can be used if the doctor documents the condition as such. The fifth character “1” indicates that the cancer is in remission.

If lymphoma is documented as in remission, it’s still assigned to the appropriate code from categories C81 to C86. Although lymphoma patients may be regarded in remission, they’re still considered to have lymphoma and should be assigned the appropriate code from categories C81-C86.

Other types of cancer can be termed as in remission, but there aren’t specific codes designated like there are for lymphoma and leukemia. Whether to use an active cancer code or a personal history of cancer code for other types of cancer that a doctor documents as in remission, will depend on what the documentation states for that date of service. Keep in mind if there’s no treatment or adjuvant therapy being directed at the primary malignancy at that time, the doctor shouldn’t use an active cancer code.

It’s important to always review the ICD-10-CM Coding Guidelines (Section I.C.2 , Chapter 2: Neoplasms, codes C00-D49) as well as any instructional notes under the codes in the tabular list of the ICD-10-CM manual in order to select the correct code, additional codes required and possible sequencing information as well.

ICD-10-CM for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

For more information, contact your provider consultant.

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 applicable state and federal laws and regulations.