Question Squamous cell lung cancer

Messages
62
Location
Largo, FL
Best answers
0
Good morning,

I am trying to get clarification on coding for Squamous cell lung cancer s/p radiation. The documentation states that the cancer is active and the treatment is to follow-up with the oncologist and he is status post radiation. I queried the provider for clarification since the documentation states status post radiation, just to make sure, and he confirmed it's active. Is the provider stating it's active enough to code it that way? Even though the documentation does not specifically state the patient is having any additional treatment except to follow up with oncologist?
 

thomas7331

True Blue
Messages
3,776
Best answers
11
If the provider states it is active, and you've queried the provider to confirm this, then you have to code it as active - you have no other choice. Per the ICD-10 guidelines: "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists." The plans for additional treatment do not affect the code choice, which is based solely on the provider's statement of the patient's condition.
 
Messages
62
Location
Largo, FL
Best answers
0
If the provider states it is active, and you've queried the provider to confirm this, then you have to code it as active - you have no other choice. Per the ICD-10 guidelines: "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists."
Thanks! I do agree with that, however auditors have stated in the past that if no treatment is directed to the particular site, it wouldn't be considered active. It can be very confusing at times.
 

thomas7331

True Blue
Messages
3,776
Best answers
11
Thanks! I do agree with that, however auditors have stated in the past that if no treatment is directed to the particular site, it wouldn't be considered active. It can be very confusing at times.
That's true if the tumor has been excised and the cancer is no longer present. In that case, if there is no more treatment then you would code it as history instead of active. But if the provider has confirmed that the cancer is still present, then it is coded as active even if there is no more treatment ordered or planned. Does that make sense?
 
Messages
62
Location
Largo, FL
Best answers
0
That's true if the tumor has been excised and the cancer is no longer present. In that case, if there is no more treatment then you would code it as history instead of active. But if the provider has confirmed that the cancer is still present, then it is coded as active even if there is no more treatment ordered or planned. Does that make sense?
It does, but how would an auditor know I queried him in order to assign the active code? Is the documentation I stated earlier sufficient? We are still on paper charts. I hope this isn't a silly question...I'm an overthinker!
 

thomas7331

True Blue
Messages
3,776
Best answers
11
It does, but how would an auditor know I queried him in order to assign the active code? Is the documentation I stated earlier sufficient? We are still on paper charts. I hope this isn't a silly question...I'm an overthinker!
Not a silly question at all!

Any queries should always be a part of the medical record, and an auditor should have access to your queries the same as they would to any other part of the record. (If you aren't keeping your queries in the medical record, then you can't really use it to assign coding and the auditor would be correct to assign an error for coding from information that isn't present in the record.) But if it is clearly stated in the record that the malignancy is active, then there really isn't a need to query the provider in the first place - you can assign the active code.
 

csperoni

True Blue
Messages
1,548
Location
Selden
Best answers
3
100% agree with @thomas7331 that if the provider states it is active, it is not the coder's responsibility to question this unless it seems obvious the provider may have made an error.
I will note that while the current guidance is to use history of once no longer being treated, that was not always the case.
This is from SGO's 2021 coding question & answers:
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, for patients not receiving any current treatment and NED, it should be history of per current guidelines. Older guidance was to use the active cancer code until remission for 5 years. I do not know when the guidelines changed, but I do know when I started in gynonc about 16 years ago, I recall several seminars being instructed to use active cancer codes until the 5 year mark.
 
Top