For an on-demand webinar, click here or navigate to MedicareProviders.Cigna.com > Provider Education > Disease-Specific Training.
The most common error in reporting malignant neoplasms is the selection of an active cancer code for a cancer that is historical. Reporting secondary sites of metastasis as a primary cancer is also a frequent mistake leading to inaccurate coding. Understanding the specific guidelines for neoplasms will improve the coding accuracy for cancer.
Site specificity is critical to accurate reporting of malignant neoplasms. A best practice is to review oncology reports to ensure that providers do not report conflicting information. In addition to the specific site of the cancer, histology may also affect the choice of diagnosis codes in some cases.
ICD-10-CM indexes neoplasms by Malignant Primary, Malignant Secondary, Ca in situ, Benign, Uncertain Behavior, and Unspecified Behavior. Unspecified behavior codes are reported when documentation does not clearly specify the type. Codes for Uncertain Behavior are only reported by pathology.
Active cancer can be reported if it is a known malignancy that is presently undergoing current treatment. Current treatment for active cancers are surgery, chemotherapy, immunotherapy, radiation therapy, hormonal therapy, and no treatment per patient’s choice. A follow-up visit for active cancer must always include treatment plan, not just “follow-up”.
History of cancer should be reported when a malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing malignancy. History of cancer or a resolved cancer should be listed in the PMH of the patient’s chart and reported with codes from subcategories Z85.0-Z85.9, personal history of malignant neoplasm.
If a patient is receiving post-treatment prophylactic therapy, such as Tamoxifen for breast cancer, it is not considered “active” cancer treatment and should be reported by assigning the Z code for Tamoxifen use, along with the code from category Z85 for the personal history of the cancer.
Note: Uncertain behavior codes are used by Pathology only.
These CPT codes can be used to report quality measures.
Patient is a 51y/o WF with PMH of obesity, anxiety, and L breast cancer in 2009. Currently undergoing chemotherapy for metastasis to liver.
Diagnosis – Breast CA mets to liver
Coded as:
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
Z85.3 Personal history of malignant neoplasm of breast
Z51.11 Long term (current) chemotherapy
Patient is a 42 y/o BF with PMH of anxiety and Stage II R breast cancer, status-post R mastectomy x 5 weeks. Currently undergoing chemotherapy for breast cancer.
Diagnosis: R breast cancer
C50.911 Malignant neoplasm of unspecified site of right female breast
Z90.11 Acquired absence of R breast and nipple
*The sole purpose of the examples is to demonstrate the application of coding guidelines discussed in the materials. Examples do not represent complete documentation of a condition, nor provide any clinical advice. Each patient and medical record is unique, and assignment of codes depends solely on the distinct documentation within an individual record.
Providers must confirm the accuracy of their diagnoses to ensure that diagnosis and coding practices comply with ICD-10-CM Official Guidelines for Coding and Reporting and all applicable legal requirements. Failure to address diagnosis inaccuracies can result in administrative sanctions and potential financial penalties. Accurate coding and submission activities allow us to provide the best benefits and resources possible to our customers.
This guide is informational and not meant to replace the clinician’s judgment when caring for the patient.
Content updated April 2023