Cracking the Code

Coding Cancer Correctly

Accurately coding cancer diagnoses all depends on clear documentation from the provider. How do you know when cancer is historical or active? Cancer is considered to be active when the patient is currently and actively being treated and managed for cancer (i.e. current chemotherapy, current pathology revealing cancer, or newly diagnosed patient awaiting treatment).On the other hand, cancer is considered to be historical when the cancer was successfully treated and patient is no longer receiving treatment (i.e. cancer was excised or eradicated, patient using adjuvant therapy for prophylactic purposes, or patient is under surveillance of recurrence).

Q: A 41-year-old woman with a history of breast cancer and status-post double mastectomy in 2016 comes in today for chemotherapy treatment for metastatic cancer to the hip and femur bone.
A: Z51.11, encounter for antineoplastic chemotherapy C79.51, secondary malignant neoplasm of bone Z85.3, personal history of malignant neoplasm of breast
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2020, Section I.C.2.m.
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