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Documentation and Coding for Neoplasms & Related Conditions December 18, 2022 Claims & Coding

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.”

Documentation & Coding Tips

Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection 

  • Classification: 
    • Use Primary Malignant, Secondary Malignant, Benign, In situ, or uncertain histologic behavior as descriptors. 
    • Avoid: “mass,” “lump,” “neoplasm,” “lesion,” or “growth” if more specific description is available 
    • Secondary malignancy: Extension, invasion, or metastasis to a site (distant or to an adjacent site). 
    • Origin: Use the words “to” and “from” in documentation to clarify origin of the neoplasm. 
    • Staging: include cancer staging in documentation if known. 
  • Anatomic location: include site, laterality. 
  • Active or current cancer: cancer still present and/or receiving treatment. 
  • Personal history of cancer: the condition has been excised or eradicated, all treatment completed, and no evidence of disease (NED). 
  • Treatment: document if treatment is for active cancer or for prophylaxis against neoplasm return. 
  • Related Conditions: Document diagnoses related to neoplasm and/or treatment 

ICD-10 

Description 

Example of when to use codes in this category  

Z85.x 

Personal History of Malignant Neoplasm 

  • Patient has a history of malignant neoplasm large intestine 2013, did well with surgical intervention & has completed all treatment. Ongoing monitoring indicates no evidence of recurrence. 

  • Patient with history of breast cancer s/p mastectomy in 2012 continues prophylactic Tamoxifen 

D0x.x 

Carcinoma in situ  

Patient diagnosed with carcinoma in situ of the hard palate 

C79.x 
C34.xx 

Secondary malignancy of bone 
Malignant neoplasm lung 

Patient recently had PET scan that shows lung cancer has spread to right femur bone 

C50.x 

Malignant neoplasm of breast 

Patient had right side mastectomy for bilateral breast cancer 3 years ago, remains on tamoxifen for active treatment. 

C61 

Malignant neoplasm of prostate 

Patient & provider have decided not to start treatment for prostate cancer, will take an observational approach. F/U by oncology every 6 months. 

Z80.x 

Family history of primary malignant neoplasm 

Patient complains of issues with blood in urine & left lower back pain. Will send for complete work up due to his mother's history of kidney cancer. 

Related Condition examples

ICD-10 

Description 

D63.0 

Anemia in neoplastic disease 

D64.81 

Anemia due to antineoplastic chemotherapy  

D70.1 

Agranulocytosis secondary to cancer chemotherapy 

G62.0 

Drug-induced polyneuropathy 

G13.0 

Paraneoplastic neuromyopathy & neuropathy

M36.0 

Dermato(poly)myositis in neoplastic disease