Documentation and Coding for Neoplasms & Related Conditions

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 

Related Condition examples

References 

• Optum EncoderPro.com for Payers - Home (encoderprofp.com) 
• Clear Up Confusion as to When Cancer Becomes “History Of” - AAPC Knowledge Center 
• ICD-10-CM 2022 Coding Manual