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
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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.
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Anatomic location: include site, laterality.
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Active or current cancer: cancer still present and/or receiving treatment.
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Personal history of cancer: the condition has been excised or eradicated, all treatment completed, and no evidence of disease (NED).
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Treatment: document if treatment is for active cancer or for prophylaxis against neoplasm return.
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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 |
|
| 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. |
| 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 |
References