Recommended documentation practices for malignancies/cancer

• Specificity (metastatic, benign, in-situ, malignant or of uncertain histologic behavior, laterality)
• Status (recently diagnosed, In remission, prophylactic therapy status post (S/P) mastectomy/removal/antineoplastic treatment, active and monitoring)
• Treatment (continue Herceptin, scheduled for surgery, refuses treatment, watchful waiting, adjuvant therapy)

Documentation tips:

When documenting cancer, consider the meaning of "current" and "history of"”:

Current: If cancer is active, to report this as current the documentation should clearly state active treatment is for the purpose of curing or palliating cancer, or states cancer is present but unresponsive to treatment; the current treatment plan is observation or watchful waiting; or the patient refused treatment.

• Active malignancies should be documented as current and treatment for cancer and/or related symptoms should be in medical decision-making (MDM)

In remission: The National Cancer Institute defines in remission as: "A decrease in or disappearance of signs or symptoms of cancer. Partial remission, some but not all signs and symptoms of cancer have disappeared. Complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body."

History of cancer: The record describes cancer as historical or "history of" and/or the record states the current status of cancer is "cancer free," "no evidence of disease," "no evidence of disease (NED)," or any other language that indicates cancer is not current.

• It is recommended to use "History of" when malignancy has been excised and there is no further treatment targeting cancer site
• Surveillance only oncology-routine follow-up care

ICD-10 guidelines for active vs. history of neoplasms:

• "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."

  Example 1: 70-year-old woman S/P mastectomy for left breast cancer, coming in for chemotherapy.
  Correct codes: C50.912 (Malignant neoplasm of unspecified site of left female breast) Z51.11 (Encounter for antineoplastic chemotherapy)

  Example 2: Patient has breast cancer S/P surgery/chemo/radiation. Patient is now on tamoxifen for five years.
  Correct code: C50.919 (Malignant neoplasm of unspecified site of unspecified female breast)
  Rationale: Documentation is supporting this as current. The record states the patient is on adjuvant therapy for breast cancer but doesn’t note the purpose of the drug (curative, palliative, or preventative). It also doesn’t say "cancer free" or "no evidence of disease." (Reference Coding Clinic Q3 2022, page14-15)
  

• "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 existing primary malignancy at that site, a code from category Z85, (Personal history of malignant neoplasm) should be used to indicate the former site of the malignancy."

  Example 1: 60-year-old man comes for follow- up visit for colon cancer removed three years ago with no recurrence and no current treatment for colon cancer.
  Correct code: Z85.038 (Personal history of malignant neoplasm of large intestine)

  Example 2: 68-year-old patient has history of right breast cancer, S/P surgery/chemo/radiation. Is on prophylactic tamoxifen for five years. No current evidence of disease.
  Correct code: Z85.3 (Personal history of malignant neoplasm of breast)
  Rationale: In this case, report history of. The documentation notes "history of" and "no current evidence of disease," and describes the purpose of the adjuvant therapy is "prophylactic."