Which of the Following Is True When Coding a Personal or Family History of a Malignant Neoplasm?

Expect to documentation for clues that tell you if a patient's cancer is active or past history.

Past Emily Bredehoeft, COC, CPC, AAPC Fellow
A hot topic in oncology is when to beginning coding history of cancer rather than active cancer. Luckily, ICD-10-CM Official Guidelines for Coding and Reporting provides an answer.

Section 1.C.two Provides Guidance

According to the ICD-10 guidelines, (Section I.C.ii.yard):
When a main malignancy has been excised but further treatment, such as additional surgery for the malignancy, radiations therapy, or chemotherapy is directed to that site, the primary malignancy lawmaking should be used until treatment is complete.
When a primary malignancy has been excised or eradicated from its site, in that location is no further treatment (of the malignancy) directed to that site, and at that place is no testify of whatsoever existing primary malignancy, a lawmaking from category Z85, Personal history of malignant neoplasm, should exist used to indicate the one-time site of the malignancy.
Section I.C.21.8 explains that when using a history code, such as Z85, we also must use Z08 See for follow-up test after completed treatment for a malignant neoplasm. This follow-up lawmaking implies the status is no longer being actively treated and no longer exists. The guidelines state:
Follow-upward codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment.
A follow-up code may exist used to explain multiple visits. Should a condition be found to accept recurred on the follow-up visit, then the diagnosis lawmaking for the condition should be assigned in place of the follow-upward code.
For instance, a patient had colon cancer and is condition postal service-surgery/chemo/radiation. The patient chart notes, "no testify of affliction" (NED). This is reported with follow-upward lawmaking Z08, commencement, and history code Z85.038 Personal history of other malignant neoplasm of large intestine, second. The cancer has been removed and the patient'southward treatment is finished.

Defining Terms with Care

For more than context, consider the meanings of "current" and "history of" (ICD-ten-CM Official Guidelines for Coding and Reporting; Mayo Clinic; Medline Plus, National Cancer Institute):
Current: Cancer is coded as electric current if the record clearly states agile handling is for the purpose of curing or palliating cancer, or states cancer is nowadays only unresponsive to treatment; the current treatment plan is observation or watchful waiting; or the patient refused handling.
In Remission: The National Cancer Institute defines in remission every bit: "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 take disappeared, although cancer still may be in the body."
Some providers say that aromatase inhibitors and tamoxifen therapy are applied during consummate remission of invasive breast cancer to prevent the invasive cancer from recurring or distant metastasis. The cancer still may be in the torso.
In remission generally is coded every bit current, as long as there is no contradictory information elsewhere in the record.
History of Cancer: The record describes cancer equally historical or "history of" and/or the tape states the current status of cancer is "cancer complimentary," "no evidence of disease," "NED," or whatever other language that indicates cancer is not current.
Co-ordinate to the National Cancer Institute, for breast cancer, the five-twelvemonth survival charge per unit for non-metastatic cancer is 80 per centum. The thought is, if after 5 years the cancer isn't back, the patient is "cancer gratis" (although cancer can reoccur after five years, it's less likely). Equally coders, information technology's important to follow the documentation every bit stated in the record. Don't go by assumptions or averages.

Active Treatment vs. Preventative Care

What if a patient with chest cancer is condition postal service-surgery/chemotherapy/radiations and is currently on tamoxifen for five years? If the patient is on tamoxifen or an aromatase inhibitor, such every bit Arimidex®, is that active treatment or preventive care (to inhibit returning cancer).
Ultimately, what determines active treatment versus preventive care is how the drug is used. For example:

• Neoadjuvant chemotherapy is medicine administered earlier surgery to reduce the size of a tumor, and possibly provide more treatment options.
• Adjuvant means "in addition to" and refers to medicine administered later surgery for treatment of cancer. Adjuvant therapy may exist chemotherapy, radiation, or hormonal therapy.

Adjuvant treatment is given after main handling has been completed to either destroy remaining cancer cells that may be undetectable; or to lower the risk that the cancer will come back.
The purpose of adjuvant medicine may be:

• Curative – to treat cancer.
• Palliative – to relieve symptoms and reduce suffering caused by cancer without effecting a cure. It likewise may exist given when there is testify of metastatic or recurrent/metastatic disease.

• Preventative or Prophylactic – to keep cancer from reoccurring in a person who has already been treated for cancer or to proceed cancer from occurring in a person who has never had cancer but is at increased risk for developing it due to family unit history or other factors.

The following examples illustrate how this affects coding:
Example one: Patient has chest cancer condition post-surgery/chemo/radiations. Patient is at present on tamoxifen for five years.
Code this case equally current. The record states the patient is on adjuvant therapy for breast cancer, merely doesn't note the purpose of the drug (curative, palliative, or preventative). It also doesn't say "cancer costless" or "no evidence of disease," or "NED."
Instance 2: Patient has history of breast cancer, status post-surgery/chemo/radiation. Is on prophylactic tamoxifen for 5 years. No current prove of disease.
In this case, study history of. The documentation notes "history of" and "no current show of disease," and describes the purpose of the adjuvant therapy is "prophylactic."
Preventive adjuvant treatments typically are for a patient with a family history of chest cancer, or who has had ductal carcinoma in situ/lobular carcinoma in situ, or lobular intraepithelial
neoplasia. The tamoxifen and aromatase inhibitor therapy, in this example, is given to prevent new breast cancer that is not related to the original site.
Tamoxifen and aromatase inhibitor therapy are used on invasive breast cancer to forestall recurrence of the original, invasive cancer. To the clinician, this is not prevention therapy, but a manner to reduce the risk of cancer recurrence locally or of distant metastasis. To code accurately, clarify with the physician the purpose of the therapy, if it's not stated.

The Provider Perspective

Do providers agree with the above guidelines, or are the clinical and coding worlds at odds?
According to a presentation by James M. Taylor, MD, CPC, providers look at cancer at a cellular level; whereas, coding guidelines look more at the organ level. In his opinion, common concerns amongst providers are:

• Some neoplasms may not be agile merely remain at a cellular level, and can go active.
• If the organ is gone and treatment is finished, yet the survival looks dismal, what does the provider tell the patient?
• The doctor says cancer, the decease certificate says cancer, but coding guidelines state "history of."
• Confusion for patients who see a "history of" diagnosis on their charts, but the doc is still saying information technology'south cancer.

"History of" Doesn't Mean a Lesser Service

I've heard providers worry well-nigh the level of medical determination-making assigned to a history of diagnosis, versus a current status diagnosis. The fear is, history of will exist seen as a less important diagnosis, which may affect relative value units. Providers contend that history of cancer follow-up visits crave meaningful review, examinations, and discussions with the patients, plus significant screening and watching to see if the cancer returns.
History of is notwithstanding an of import diagnosis. Encourage providers to document the piece of work they practice; and if it is a visit based on counseling, they should utilise a time statement when warranted and supported.
Instance one: A total of 25 minutes was spent face to face with the patient during this see and greater than fifty percent of the time was spent on counseling on the side effects from therapy and adjuvant hormonal therapy plans.
Case two: A total of 31 minutes was spent confront to face with the patient during this encounter and greater than fifty percentage of the time was spent on counseling on the long-term side furnishings of previous chemotherapy, adjuvant hormonal therapy, addressing patient recurrence concerns, and follow-up plans.
When deciding whether to assign "history of" or "current" cancer diagnoses, it all comes down to documentation. Does the documentation tell yous if the cancer is even so at that place, or does information technology note "no testify of illness?" Is the patient still receiving adjuvant therapy; and if and so, what is the purpose of that therapy? Clear, specific documentation is required to clinch proper coding. Providers should document:

• Histological site or behavior
• Location and whether the neoplasm is primary, secondary, or carcinoma in situ
• The intent of the adjuvant therapy: curative, palliative, or preventative

"History of" doesn't hateful the cancer volition non come up back, and never can be coded equally active, again. If the condition returns, you'll again code it equally active cancer.
Resource
Johns Hopkins Medicine, Neoadjuvant and Adjuvant Chemotherapy,
www.hopkinsmedicine.org/breast_center/treatments_services/medical_oncology/neoadjuvant_adjuvant_chemotherapy.html
AHA Coding Dispensary Outset Quarter 2005; AHA Coding Clinic for ICD-9 Quaternary Quarter 2006
AHIMA. HX OF Presentation 04122007 Web-based Coding Preparation-Oncology Services Coding in Hospitals
Mayo Clinic: www.mayoclinic.org/
Elsevier Clinical Solutions ICD-10 CodingNational Cancer Institute: www.cancer.org
AAPC, James M. Taylor, Md, CPC, "When Clinical and Coding Worlds Collide"
Medline Plus, https://medlineplus.gov/
ICD-10-CM Official Guidelines for Coding and Reporting, 2018
American Cancer Society: world wide web.cancer.gov
Author Note: A special acknowledgement and thanks goes to Anup-ama Kurup Acheson, MD, of Providence Cancer Center in Portland, Ore., for her aid in researching and reviewing this article.

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Emily Bredehoeft, COC, CPC, AAPC Fellow, is a coder at Providence Medical Group, Finance Coding Department, supporting oncology and hematology. She is the fellow member development officer of the Columbia River Coders, Portland, Ore., local chapter.

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Source: https://www.aapc.com/blog/40016-clear-up-confusion-as-to-when-cancer-becomes-history-of/

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