Coding Cancer and Cancer-Related Treatments

Coding Cancer and Cancer-Related Treatments

• To properly code a neoplasm, specify if the neoplasm is benign, in situ, malignant or of uncertain histology. Any metastases should be noted.
• All known treatments and complications should be documented.
• A statement of "History of" indicates the condition is resolved. Don't document "History of" for members with active cancer or current treatment.
• A code from Z85.x , Personal history of malignant neoplasm, is appropriate if a primary malignancy has been previously excised or eradicated from its primary site and there is no further treatment.

Tips to Consider

• Include patient demographics such as name, date of birth and date of service in all progress notes.
• Document legibly, clearly and concisely.
• Ensure a credentialed provider signs and dates all documents.
• Document how each diagnosis was monitored, evaluated, assessed and/or treated on the date of service.
• Note complications with an appropriate treatment plan.
• Take advantage of the Annual Health Assessment or other yearly preventative exam as an opportunity to capture conditions impacting member care.

Recursos

• ICD-10-CM Official Guidelines for Coding and Reporting 
• Chapter 2: Neoplasms (C00-D49) 

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_{The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients' conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials.}

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