Coding corner: When is it appropriate to use a ‘history of’ code when reporting cancer?

As you’ve read in “Coding corner” before, selecting the 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 can help. Here’s what you need to know about coding for cancer.

Your documentation should always specify one of the following:

• The cancer is active and still being treated.
• The cancer is no longer active or there’s no recurrence and no further treatment is necessary.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.”

Scenario one:
A patient with a history of breast cancer and mastectomy of the right breast — but who has no evidence of cancer or isn’t currently receiving treatment — comes in for an office visit. The provider documents that there are no presenting problems that may affect the overall plan of care and that the patient isn’t receiving active adjuvant therapy. In this scenario, a personal history code should be used. Example: Z85.3 Personal history of malignant neoplasm of breast

Patients who currently have cancer
In the scenarios below, the cancer is still being actively managed, so a current malignancy code should be used. Example: C50.111 Malignant neoplasm of central portion of right female breast

Scenario two:
A patient diagnosed with breast cancer returns to the office for a visit after a mastectomy and is currently receiving radiation therapy.

Scenario three:
A patient, diagnosed with breast cancer last year, had a mastectomy followed by radiation and chemotherapy. She was hormone receptive positive and is currently taking Arimidex^®.

In summary
To ensure best documentation practices, refer to the ICD-10-CM guidelines to assist with the code selection that clearly supports the documentation. Clinical evidence needs to be documented to support an active diagnosis of cancer.

The documentation must clearly state that the cancer is currently and actively being treated and managed. If the cancer has been excised or eradicated and there’s no evidence of recurrence and no further treatment is needed, then it’s appropriate to use a “personal history” code.

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.