Clear Up Confusion as to When Cancer Becomes “History Of”
Look to documentation for clues that tell you if a patient’s cancer is active or past history.
By Emily Bredehoeft, COC, CPC, AAPC Fellow
A hot topic in oncology is when to start coding history of cancer rather than active cancer. Luckily, ICD-10-CM Official Guidelines for Coding and Reporting provides an answer.
Section 1.C.2 Provides Guidance
According to the ICD-10 guidelines, (Section I.C.2.m):
When a primary malignancy has been excised but further treatment, such as additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is complete.
When a primary malignancy has been excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
Section I.C.21.8 explains that when using a history code, such as Z85, we also must use Z08 Encounter for follow-up examination after completed treatment for a malignant neoplasm. This follow-up code implies the condition is no longer being actively treated and no longer exists. The guidelines state:
Follow-up 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 be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code.
For example, a patient had colon cancer and is status post-surgery/chemo/radiation. The patient chart notes, “no evidence of disease” (NED). This is reported with follow-up code Z08, first, and history code Z85.038 Personal history of other malignant neoplasm of large intestine, second. The cancer has been removed and the patient’s treatment is finished.
Defining Terms with Care
For more context, consider the meanings of “current” and “history of” (ICD-10-CM Official Guidelines for Coding and Reporting; Mayo Clinic; Medline Plus, National Cancer Institute):
Current: Cancer is coded as current if the record clearly states 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.
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.”
Some providers say that aromatase inhibitors and tamoxifen therapy are applied during complete remission of invasive breast cancer to prevent the invasive cancer from recurring or distant metastasis. The cancer still may be in the body.
In remission generally is coded as current, as long as there is no contradictory information elsewhere in the record.
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,” “NED,” or any other language that indicates cancer is not current.
According to the National Cancer Institute, for breast cancer, the five-year survival rate for non-metastatic cancer is 80 percent. The thought is, if after five years the cancer isn’t back, the patient is “cancer free” (although cancer can reoccur after five years, it’s less likely). As coders, it’s important to follow the documentation as stated in the record. Don’t go by assumptions or averages.
Active Treatment vs. Preventative Care
What if a patient with breast cancer is status post-surgery/chemotherapy/radiation and is currently on tamoxifen for five years? If the patient is on tamoxifen or an aromatase inhibitor, such as 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 before surgery to reduce the size of a tumor, and possibly provide more treatment options.
- Adjuvant means “in addition to” and refers to medicine administered after surgery for treatment of cancer. Adjuvant therapy may be chemotherapy, radiation, or hormonal therapy.
Adjuvant treatment is given after primary treatment 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 also may be given when there is evidence 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 keep cancer from occurring in a person who has never had cancer but is at increased risk for developing it due to family history or other factors.
The following examples illustrate how this affects coding:
Example 1: Patient has breast cancer status post-surgery/chemo/radiation. Patient is now on tamoxifen for five years.
Code this case 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,” or “NED.”
Example 2: Patient has history of breast cancer, status post-surgery/chemo/radiation. Is on prophylactic tamoxifen for five years. No current evidence of disease.
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.”
Preventive adjuvant treatments typically are for a patient with a family history of breast 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 case, 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 prevent recurrence of the original, invasive cancer. To the clinician, this is not prevention therapy, but a way 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 among providers are:
- Some neoplasms may not be active but remain at a cellular level, and can become 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 death certificate says cancer, but coding guidelines state “history of.”
- Confusion for patients who see a “history of” diagnosis on their charts, but the doctor is still saying it’s cancer.
“History of” Doesn’t Mean a Lesser Service
I’ve heard providers worry about the level of medical decision-making assigned to a history of diagnosis, versus a current status diagnosis. The fear is, history of will be seen as a less important diagnosis, which may affect relative value units. Providers argue that history of cancer follow-up visits require meaningful review, examinations, and discussions with the patients, plus significant screening and watching to see if the cancer returns.
History of is still an important diagnosis. Encourage providers to document the work they do; and if it is a visit based on counseling, they should use a time statement when warranted and supported.
Example 1: A total of 25 minutes was spent face to face with the patient during this encounter and greater than 50 percent of the time was spent on counseling on the side effects from therapy and adjuvant hormonal therapy plans.
Example 2: A total of 31 minutes was spent face to face with the patient during this encounter and greater than 50 percent of the time was spent on counseling on the long-term side effects 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 you if the cancer is still there, or does it note “no evidence of disease?” Is the patient still receiving adjuvant therapy; and if so, what is the purpose of that therapy? Clear, specific documentation is required to assure 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 mean the cancer will not come back, and never can be coded as active, again. If the condition returns, you’ll again code it as active cancer.
Johns Hopkins Medicine, Neoadjuvant and Adjuvant Chemotherapy,
AHA Coding Clinic First Quarter 2005; AHA Coding Clinic for ICD-9 Fourth Quarter 2006
AHIMA. HX OF Presentation 04122007 Web-based Coding Training-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: www.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 help in researching and reviewing this article.
Emily Bredehoeft, COC, CPC, AAPC Fellow, is a coder at Providence Medical Group, Finance Coding Department, supporting oncology and hematology. She is the member development officer of the Columbia River Coders, Portland, Ore., local chapter.