Oncology & Hematology Coding Alert

Understand how to document and support active or history Dx coding.

In part 1 of this series, we looked at problems with cancer reporting identified by Office of Inspector General (OIG) auditors. Specifically, OIG investigators “use the terms ‘supported’ or ‘not supported’” in their reports “to denote whether or not the diagnoses codes submitted to the Centers for Medicare & Medicaid Services [CMS] by health plans in risk adjustment coding were evidenced in the medical records.”

In other words, in their audits, the OIG was looking for documentation in office and progress notes, the history of present illness (HPI), physical exam (PE), and assessment & plan (A&P) that supported the diagnosis and, in turn, determined medical necessity for a patient’s treatment plan.

At the center of the OIG’s audits is one very simple coding error, however: the distinction between coding for an active cancer that is receiving ongoing treatment or management, and coding for a history of cancer. The OIG reported that the documentation for the active diagnosis codes submitted in the audits reflected historical conditions, as there was no evidence of treatment or ongoing management and therefore the diagnosis codes reported were not supported.

Understand When Cancer Is Regarded as Active

In general, most types of cancer are considered an acute condition, and best practice would be to document active cancer in the A&P with support. When active cancer is undergoing treatment or management, support statements such as any of the following should be acceptable:

• Treatment is directed to the cancer site for curing or palliating.
• The patient has lung cancer, was treated with radiation therapy, and is unresponsive to treatment.
• The patient has prostate cancer and on “active surveillance” or “watchful waiting” without treatment as the malignant tumor is early stage, slow growing, low grade — or the patient is too frail to undergo treatment or they opt for hospice. Documentation must state “active surveillance” and the reason why.
• Pathology shows malignancy on the right lower outer quadrant of female breast, but treatment has not yet started.
• The patient has refused any further treatment or is on break (drug holiday).
• The patient is on adjuvant therapy, which may include additional surgery, radiation therapy, chemotherapy, immunotherapy, and hormonal therapy.

Note for breast or ovarian cancer: For breast cancer diagnoses when the cancer is active, documentation must also include hormone receptor (HR) status for estrogen and/or progesterone, and human epidermal growth factor receptor (HER) status.

When all three receptors are positive, documentation should include notation of HR+ and HER2+. This is also known as triple positive.

When all three receptors are negative, documentation should include notation of HR- and

HER2-. This is also known as triple negative, which is important as hormone therapy would not

be used as treatment for triple-negative receptors.

You should then code estrogen and progesterone HR and HER status with the appropriate codes from Z17.- (Estrogen, and other hormones and factors receptor status).

Know When to Use a History Code                                           

Oncology coders often struggle with knowing when to start coding a history of cancer rather than active cancer, especially when the patient is on adjuvant hormone therapy. In diagnosis coding, per Guideline I.C.2 of the ICD-10-CM Official Guidelines for Coding and Reporting, “history of” means the condition is historical and no longer exists as current. This occurs when:

• The malignancy has been previously excised or eradicated from its original site, there is no further treatment (continuum of care) directed toward the original cancer site, and there is no evidence of any existing primary malignancy at the cancer site 
• Providers prescribe hormonal therapy as preventive only for cancers such as breast or prostate, and they document it with preventive words such as “prophylactic,” “maintenance,” “excised/eradicated more than 10 years ago with no active treatment,” or “no evidence of disease (NED)” 
• The assessment documents something like “History of breast cancer currently on maintenance Tamoxifen.” See the following note:
  • HPI: Follow up for her breast cancer
  • Assessment: Breast Cancer (“History of” would be best practice)
  • Plan: Patient continues with maintenance Arimidex
  • Return in 3 months for level check
  • You would code this example as “historical,” and you should not use a risk adjustment code. The provider has correctly documented the word “maintenance,” as this word indicates the medication is being given prophylactically.
• Historical surveillance to monitor for recurrence of the cancer while the patient is on prophylactic medication

Avoid Confusion Over Adjuvant Therapy

The term “adjuvant” means “in addition to” and refers to medicine administered during or after an active cancer diagnosis and can be chemotherapy, radiation, immunotherapy, targeted therapy, or hormonal therapy. The purpose of the adjuvant medicine should be documented precisely, using language from the following list, as that will affect coding for active or historic cancer:

• Curative means to treat cancer. Adjuvant treatment is usually given after primary treatment has been completed, either to destroy the remaining cancer cells that may be undetectable, to stop growth of hormones or cells, or to lower the risk that the cancer will come back. Coding should be for active cancer.
• Palliative is for treatment to relieve symptoms and reduce suffering caused by cancer without effecting a cure. Palliative care might also occur when there is evidence of metastatic or recurrent/metastatic appearance. Coding should be for active cancer.
• Preventive or prophylactic represent treatment in two different scenarios:
  • When a person has already been treated for the cancer, and the provider documents “the cancer is excised, eradicated, with no evidence of disease,” “the treatment is to keep cancer from reoccurring, returning,” “the drug (such as tamoxifen) is given for prophylactic, maintenance,” or similar words if for breast cancer. Coding should be historic.
  • When documentation states “Tamoxifen (or other preventive drug) is given 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,” coding should be for family history of cancer as appropriate, as there is no active cancer being treated. Report Z80.3 (Family history of malignant neoplasm of breast) for family history of breast cancer.
• Neoadjuvant therapy refers specifically to chemotherapy administered before surgery, usually to reduce the size of a tumor to make it operable and possibly provide more treatment options. In this case, the cancer is active and should be coded as active cancer.

Note additional breast, ovarian, or prostate cancer coding: Usually, when the patient undergoes adjuvant hormonal therapy for breast or ovarian cancer, the patient will have positive hormone receptors, and this can span many years. In this case, the neoplasm is considered malignant and active throughout the entire duration of hormone therapy treatment. Consequently, the cancer should be coded as active, and you should also observe these guidelines:

• Documentation must state the receptor status as described previously, so you should add the appropriate Z17.- codes as secondary to the active cancer code.
• For men undergoing hormone therapy such as androgen deprivation therapy (ADT) for prostate cancer, you should add a code from Z19.- (Hormone sensitivity malignancy status) as a secondary code to C61 (Malignant neoplasm of prostate) for the active cancer if applicable.
• In addition to active prostate cancer and secondary Z19.- codes, you should add R97.21 (Rising PSA following treatment for malignant neoplasm of prostate), also if applicable.
• These additional Z codes are secondary to the active cancer diagnosis codes; the provider should clearly document the conditions so you can code them.

Remember: Refer to ICD-10-CM to add other Z codes affecting estrogen receptors under Z79.8 (Other specified postprocedural states), such as Z15.0 (Genetic susceptibility to malignant neoplasm) or Z78.0 (Asymptomatic menopausal state).

Learn From These Examples to Document Cancer Status and Treatment Correctly

As we have seen, providers need to carefully document the purpose of the treatment and/or medication and the status of the cancer. The following examples illustrate how this affects coding.

Example 1: The record states, “The patient is on adjuvant therapy for breast cancer. The patient had surgery, chemotherapy, and radiation five years ago, and is currently on tamoxifen and has been for five years.”

This example presents two problems. First, the note doesn’t state the purpose of the drug (whether it is curative, palliative, or preventive). It also doesn’t say “cancer free” or “no NED.” The note is further missing HR+ and HER+ status, which is an essential factor for active cancer with ongoing adjuvant hormone therapy. 

In this situation, you will need to query the provider to see if you should report an active cancer diagnosis, as all the elements of the record should indicate the cancer is ongoing.

A better note would read something like, “The patient has positive hormone receptors, or HR+ or ER+PR+ and is on adjuvant therapy, Tamoxifen for ten years to stop cell growth or for curative purposes. The patient had surgery, chemotherapy, and radiation five years ago.” 

Example 2: The record states, “Patient has history of breast cancer, status post-surgery/chemo/radiation and is on prophylactic tamoxifen for five years. There is no current evidence of disease.”

In this case, you would report a history code, because the documentation notes “history of,” there is “no current evidence” of active condition, and the drug tamoxifen is being administered for preventive purposes.

The bottom line: Without clear and concise documentation, coders may incorrectly report diagnosis codes, which could cause overpayment that will have to be repaid, or underpayment that will result in financial loss and that will affect the treatment and proper care of the patient.

Delly Parham, CRC, CPMA, CPC, Risk Adjustment Coder