Complete and accurate coding is crucial in determining medical necessity, and supports the delivery of high-quality ongoing patient care. Because coding correctly for cancer can be particularly complex, Harvard Pilgrim would like to offer some reminders and guidelines.
Neoplasms, tumors, and masses
When coding for cancer, it is important to provide detailed documentation. A common issue is that cancer and neoplasms are documented interchangeably in a medical record. Because neoplasms and tumors may or may not be cancerous, please be sure to accurately document in the chart whether they are benign or malignant. In addition, the term “mass” is not regarded as a neoplastic diagnosis, and should not be used to refer to a neoplastic condition.
Other important cancer documentation reminders:
- For malignancies that have spread, remember to code the primary malignancy, as well as any secondary/metastatic malignancy, and indicate that it spread from the primary to the secondary site.
- Document if the malignancy is acute or chronic, in remission or not having achieved remission, relapsed, recurrent, or “history of cancer.”
- Include any complications, related conditions, and treatment, and link the condition to the neoplasm using terms like “due to,” “caused by,” or “secondary to.”
- Include any active treatment, such as chemotherapy, radiation, or immunotherapy, so it is clear that the cancer is current/active and not historical. (A primary malignancy is considered current and active until treatment is complete; if a site has been excised but additional surgery, chemotherapy, or radiation are directed to that site, it is still considered active.)
- When a primary malignancy has been excised or eradicated and there is no further treatment of the malignancy to that site, and no evidence of any existing primary malignancy, use a code from category Z85 (personal history of malignant neoplasm) to indicate the former site of the malignancy.
In leukemia and multiple myeloma, among other conditions, documentation often refers to “remission.” It is important to note that this should never be used interchangeably with “personal history of,” as the latter is appropriate only when the documentation states that the condition no longer exists.
For more information, refer to the 2018 ICD-10-CM Official Guidelines for Coding and Reporting.