Wiki Active vs history of malignancy

rachaelwilleford

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So I'm doing a little research to answer a question more in depth and found this from Health Choice of Arizona. I know what I think about it and how the guidelines apply, but I wanted to see what some of my tried and true oncology people think.

"My patient is a breast cancer survivor, status post double mastectomy and taking Tamoxifen. Can I code the cancer as current, since she is under treatment, or should I code Z85.3 for the history for breast cancer? A: Since the patient is under treatment with Tamoxifen, choose a code from category C50, malignant neoplasm of breast. ICD-10 coding guidelines note that it is appropriate to code for “active cancer” when the patient is undergoing treatment, even if the malignancy has been excised."
 
So I'm doing a little research to answer a question more in depth and found this from Health Choice of Arizona. I know what I think about it and how the guidelines apply, but I wanted to see what some of my tried and true oncology people think.

"My patient is a breast cancer survivor, status post double mastectomy and taking Tamoxifen. Can I code the cancer as current, since she is under treatment, or should I code Z85.3 for the history for breast cancer? A: Since the patient is under treatment with Tamoxifen, choose a code from category C50, malignant neoplasm of breast. ICD-10 coding guidelines note that it is appropriate to code for “active cancer” when the patient is undergoing treatment, even if the malignancy has been excised."

That was the directive at my most recent risk adjustment auditing position. If the patient was receiving adjuvant therapy such as tamoxifen, the cancer should be coded as current, because that's the reason for the treatment.

It was hard for me to adjust to that way of thinking, after having it drilled into my head for so many years that it's a history once it is excised! I'm not sure if guidelines have changed, or just the interpretation of the guidelines?
 
That was the directive at my most recent risk adjustment auditing position. If the patient was receiving adjuvant therapy such as tamoxifen, the cancer should be coded as current, because that's the reason for the treatment.

It was hard for me to adjust to that way of thinking, after having it drilled into my head for so many years that it's a history once it is excised! I'm not sure if guidelines have changed, or just the interpretation of the guidelines?
Hormonal therapy is not always adjuvant therapeutic treatment though. It is often used as a prophylactic treatment in patients who are higher risk of recurrence. Depending on the documentation, the patient could have no evidence of disease, and therefore treatment is not being aimed at the site of cancer (because there is no longer a site of cancer).

It's mainly interpretation, and there are differing opinions among providers. It really comes down to the documentation given by the provider in the note.
 
For a patient on tamoxifen, I would code that as C50.--- unless otherwise stated by provider.
The Society of Gynecologic Oncology provides this coding advice for active vs history of:

How long can you use the cancer diagnosis (C56.1-9) for a patient once they have completed treatment?​

Historically the primary cancer codes were used until the patient had been in remission for 5 years. However recent guidelines state that when the primary has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy at that site, it is appropriate to use the personal history code. Both are recognized for patients who are on surveillance. For patients on treatment, including maintenance, the primary cancer code should be used.
 
For a patient on tamoxifen, I would code that as C50.--- unless otherwise stated by provider.
The Society of Gynecologic Oncology provides this coding advice for active vs history of:

How long can you use the cancer diagnosis (C56.1-9) for a patient once they have completed treatment?​

Historically the primary cancer codes were used until the patient had been in remission for 5 years. However recent guidelines state that when the primary has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy at that site, it is appropriate to use the personal history code. Both are recognized for patients who are on surveillance. For patients on treatment, including maintenance, the primary cancer code should be used.
So even if the provider documents the breast cancer as no evidence of disease? (By the way, thanks for the Gyn/Onc reference.)
 
So even if the provider documents the breast cancer as no evidence of disease? (By the way, thanks for the Gyn/Onc reference.)
I personally would code C50.--- if the patient is currently taking tamoxifen for the breast cancer as I would consider it maintenance treatment. There are many coders who would differ in opinion on that and code history of.
I've never had an audit (internal company audit or external individual claim review) officially disagree with that stance.
 
Is anyone experiencing issues with insurance paying claims that have a Z code personal history or Z08 listed?
 
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