Compliance Fiasco Coming in Tamoxifen Coding?

Compliance Fiasco Coming in Tamoxifen Coding?

By Sheri Poe Bernard, CPC, COC, CCS-P

I see a compliance fiasco waiting to happen in risk adjustment regarding tamoxifen and breast cancer coding.
I was a minority of one regarding active breast cancer vs. history of breast cancer coding at a discussion during a recent HEALTHCON session, but I feel confident that I am the one doing it correctly.
The consensus of RA coders attending the presentation was that a patient who has completed treatment for breast cancer, but is still taking tamoxifen can confidently be coded as having breast cancer. I disagree.
The coders argued that a 2009 Coding Clinic for ICD-9-CM regarding Herceptin supports tamoxifen as a treatment for active breast cancer. The Coding Clinic:
Herceptin Therapy for Breast Cancer
Question: A patient had a malignant breast neoplasm excised three years ago and has completed radiation and chemotherapy. Currently there is no evidence of residual disease on exam, on radiographic images or histologically. However, the patient is receiving consolidative treatment for breast cancer with Herceptin indicated for five years. How is maintenance on Herceptin coded?
Answer: Assign code 174.9 Malignant neoplasm of female breast, unspecified as the first-listed diagnosis, since Herceptin is considered cancer treatment. Assign code V58.69, Long-term (current) use of other medications, for the Herceptin maintenance. Herceptin therapy is not antineoplastic chemotherapy, but is a biological adjuvant treatment for women with breast cancers that are HER2 positive (with cancer cells overexpressing Human Epidermal Growth Factor Receptor 2).
My issue is that Herceptin and tamoxifen are very different in their action and purpose. Herceptin is an adjuvant therapy, while tamoxifen is a hormonal therapy. Go go to the federal National Institute of Cancer website,, to read that there is a difference between the two therapies, described as follows:
Adjuvant chemotherapy uses drugs to kill cancer cells. Research has shown that adjuvant chemotherapy for early-stage breast cancer helps to prevent the cancer from returning.
Hormonal therapy deprives breast cancer cells of the hormone estrogen, which many breast tumors need to grow. A commonly used hormonal treatment is the drug tamoxifen, which blocks estrogen’s activity in the body. Studies have shown that tamoxifen helps prevent the original cancer from returning and also helps to prevent the development of new cancers in the other breast.
Herceptin is adjuvant therapy, tamoxifen is hormonal therapy.

To connect all the dots on the difference between the two therapies, go to the records for a 2007 ICD-9-CM Coordination and Maintenance committee meeting, in which the committee discussed the V07.5x codes. These codes all report agents affecting estrogen receptors and estrogen levels. Tamoxifen is among the drugs reported with these codes; Herceptin is not. The meeting document said, in part:
The ICD-9-CM distinguishes between current cases of cancer and personal history of cancer. The use of long term prophylactic agents to prevent recurrence of disease raises questions as to when treatment is actually complete (credit clay). This issue was raised with gynecologists at ACOG. These agents are used to prevent recurrence and metastasis, so classifying their use as prophylactic is valid, regardless of whether a cancer code or a V code for history of cancer is used.(emphasis mine)
In other words, agents including tamoxifen may be used for active cancer treatment OR as prophylaxis in history of cancer, based on the rest of the patient’s treatment “history.” Rejecting active cancer as a code leaves a big HCC behind in risk adjustment, but it represents money that may be wrongly acquired, if the only current “treatment” is tamoxifen.
I’m a conservative coder. I teach RA coders that a prescription for tamoxifen is not support that a cancer is active; other support is required.
And if an insurance plan wants to follow a different rule, fine. The plan is the one taking the risk. But I would never teach RA coders that tamoxifen is slam-dunk documentation for breast cancer. There is too much documented through the federal government telling me otherwise.

Sheri Poe Bernard

About Has 8 Posts

Sheri Poe Bernard, COC, CPC, CPC-I, CDEO, CRC, CCS-P, is the author of the AMA’s publications Risk Adjustment Documentation and Coding; ICD-10-CM Chronic Disease Cards; and Netter’s Atlas of Surgical Anatomy for CPT® Coding. She is former vice president of clinical coding content at AAPC. Bernard is a member of the Salt Lake City, Utah, local chapter.

7 Responses to “Compliance Fiasco Coming in Tamoxifen Coding?”

  1. Sally Thibodeaux says:

    I agree with you 100%!

  2. Lynne Padilla says:

    Sheri- You are not alone on this island. I agree with you 100%!

  3. Stacey Hernandez says:

    I think you should review Coding Clinic, Q 4 2008 V Code Update, which states in part:
    Agents affecting estrogen receptors or levels may be administered prophylactically for patients with a personal history of cancer in order to prevent future recurrence or for patients who have risk factors for developing a particular type of cancer, such as a family history or genetic susceptibility for breast cancer. Codes from subcategory V07.5 should only be assigned if the drug is being administered prophylactically. They should not be assigned if the drug is being given as part of current cancer treatment. In this case, the current cancer and code V58.69, Long-term (current) use of other medications, should be assigned instead of a code from subcategory V07.5.

  4. Cindy Bondurant, CPC, CCS-P, CPMA, CEMC says:

    I think the KEY phrase may be “part of current cancer treatment”. I would report current active disease only when documentation supports “part of current” not the only treatment – especially when the physician is not an oncologist, does not name the oncologist, does not mention the cancer status, or do anything other than list breast cancer in past history. I looked at a record that stated only breast cancer – no dates – and medications as tamoxifen March 2011. Some people count that as C50.919 Malignant neoplasm of unspecified site of unspecified female breast. As an auditor, I would not accept that. No MEAT, No TAMPER.

  5. Kim Bair, CHONC, CPC, COC, CRC says:
    The definition of Adjuvant Therapy found on the National Cancer Institutes web site includes Hormonal Therapy as a type of Adjuvant Therapy.

  6. Brad Howard, CPC, ICD-10 CM/PCS Trainer says:

    Sheri, I have to disagree. I understand where you’re coming from in differentiating between a true adjuvant therapy, and a prophylactic therapy, however the consensus by providers and payors alike is that receiving hormonal therapy following a cancer diagnosis/treatment is considered active treatment. I would only code ‘history of’ cancer if the Tamoxifen is explicitly documented as a prophylactic measure. In your article above, you state that Tamoxifen can be used either “In active cancer or as prophylaxis,” which I agree with, but I do not feel it is appropriate for a coder to assume one or the other.
    I would review the Healthcare Business Monthly article by Emily Bredehoeft, found in the AAPC Knowledge Center ( In this article Emily advises that unless the treatment is specified as prophylactic within the chart note, the cancer should be coded as active.

  7. Stephen Guenther says:

    I have encountered the same issue: while the coding clinic attempts to clarify long term use of hormone therapy as active treatment, the key is not the medication that is given, but the current documentation by the provider as to what the medication is being used for. Is it “prophylactic” or is it “active” treatment directed at the site. Coding guidelines direct coders very clearly when a primary malignancy has been previously excised or eradicated from its site AND there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from Z85 should be used to indicate the former site of the malignancy. Prophylactic long term adjuvant chemotherapy does not supersede the guideline and should not be used to justify coding from C50-D49 in order to get the claim paid. The key is what is documented by the provider. When active treatment is completed, guidelines direct coders to report a code from Z85. It may be that the Q3 2009 coding clinic referenced may need to be revised – a lot of data and practices have evolved, and current therapies and indications for therapy may no longer apply as it did 10 years ago. In my opinion, based on the information that I outlined, if the provider is referring to the cancer as a “history of, NED”, or wording to that effect, REGARDLESS of whether the payers agree or not, Z85 is appropriate and not a code from C50-D49.