It is quite often observed that coders struggle when they are allowed to code encounters related to current malignancy or personal history of malignancy. What might be the exact reason for it? If you guess, the answer would be the lack of understanding of the terms current malignancy and history of malignancy and also the official coding guidelines.
This article provides you a clear picture on how to utilize the codes for the proper code assignment of active cancer and personal history of cancer.
The most important factor that you need to consider when coding current malignancy and history of malignancy is the â€œTreatment occurrenceâ€.
Basically, when you start coding an encounter related to malignancy cases, you need to check out if any treatment is directed towards the cancer site or not. The medical record must be scrutinized to determine the nature of malignancy as current or history based on the treatment provided to the cancer site.
Active or current malignancy: A primary malignancy should be coded to its active neoplasm code if treatment is directed to the cancer site. This applies even when the primary malignancy has been excised but further treatments as listed below is provided to that site.
- Radiation therapy
- Targeted therapy
- Hormone therapy
- Stem cell transplant
A 41 year old female patient presented for chemotherapy after right mastectomy for breast cancer.
In this example, the primary malignancy of right breast has been excised but still the chemotherapy treatment is directed to the cancer site. Therefore you need to assign active cancer code C50.911 for this scenario.
Personal history of malignancy: A malignancy is considered as â€œhistory ofâ€ if it meets all the below criteria:
- The primary malignancy has been previously excised or eradicated.
- There is no further treatment directed to that site of the primary malignancy.
- There is no evidence of any existing primary malignancy at that site.
Codes from category Z85 should be used to report cancer history codes. However this category is further divided to code for the primary and secondary malignancy as well.
Code Z85.0 – Z85.7:
A code from category Z85.0-Z85.7 should be used to report the former site of a primary malignancy only. NEVER USE this code to report history of secondary, metastatic sites.
- Z85.0 Personal history of malignant neoplasm of digestive organs
- Z85.1 Personal history of malignant neoplasm of trachea, bronchus and lung
- Z85.2 Personal history of malignant neoplasm of other respiratory and intrathoracic organs
- Z85.3 Personal history of malignant neoplasm of breast
- Z85.4 Personal history of malignant neoplasm of genital organs
- Z85.5 Personal history of malignant neoplasm of urinary tract
- Z85.6 Personal history of leukemia
- Z85.7 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues
A patient underwent mastectomy for breast cancer and adjunct chemotherapy two years ago. At this time the patient is no longer receiving treatment and there is no sign of remaining tumor.
In this example, there is no treatment directed to the malignant site after its excision from the site. Therefore you need to assign â€œpersonal historyâ€ code Z85.3 for this scenario.
A code from category Z85.8 can be used to report either the former site (primary) or sites of secondary malignancy.
- Z85.81 Personal history of malignant neoplasm of lip, oral cavity, and pharynx
- Z85.82 Personal history of malignant neoplasm of skin
- Z85.83 Personal history of malignant neoplasm of bone and soft tissue
- Z85.84 Personal history of malignant neoplasm of eye and nervous tissue
- Z85.85 Personal history of malignant neoplasm of endocrine glands
- Z85.89 Personal history of malignant neoplasm of other organs and systems
For example, consider the diagnosis â€œhistory of malignant neoplasm of tongue, primaryâ€. This condition is not found in code category Z85.0-Z85.7. As per the guidelines, category Z85.8 may be reported for either a primary or secondary malignancy. Therefore the appropriate code would be Z85.810, Personal history of malignant neoplasm of tongue which falls under the category Z85.8.
The term â€œpersonal historyâ€ should not be confused with â€œin remissionâ€. Cancer is said to be in remission when the signs and symptoms of your cancer are reduced but not cured. It can be either partial or complete that depends on the amount of measurable tumor in the body. However personal history denotes no evidence of any existing tumor in the body.
In ICD-10-CM, the malignant conditions that can be categorized as â€œin remissionâ€ are
- multiple myeloma
Other cancers are identified as active disease, meaning the condition is still present or still being treated, or history of cancer, meaning the condition has been eradicated and all treatment completed.
Happy learning! Happy coding!