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