Oncology & Hematology Coding Alert

And don’t forget: the reason for the encounter always comes first.

Codes from Z77-Z99 provide significant information about risks and influences on a patient’s health. Using them can create a detailed picture of a patient’s medical history. In oncology coding, that means the Z80.- (Family history of primary malignant neoplasm) and Z85 (Personal history of malignant neoplasm) and Z86.0- (Personal history of in-situ and benign neoplasms and neoplasms of uncertain behavior) code categories carry a great deal of importance.

It also means the codes carry a number of myths with them that must be dispelled if you are to use them correctly. Read on to find out how to bust them and improve the quality of your reporting.

Myth 1: You Use Z85.- or Z86.00- When the Provider Is No Longer Treating the Patient

This myth is partially true. You will use a site-specific code from Z85.- when “there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site,” (emphasis retained) according to ICD-10-CM guideline I.C.2.m.

But you can use Z85.- or a Z86.00- code when your oncologist is monitoring the patient to ensure the condition is, or continues to be, in remission. So, providing the condition has fully ended and the patient is no longer on a treatment plan or medication, you’ll use a code from Z85.- or Z86.00 along with Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm).

Remember: As the Code first instruction for the Z85.- or Z86.00 codes indicate, you’ll code Z08 or Z09 as appropriate first under applicable circumstances. As guideline I.C.21.c.4 instructs, “the reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).”

Myth 2: You Cannot Use a History Code When a Patient Is Receiving Treatment

This myth is also partly true. As with myth 1, your application of a history code depends on the status of the malignant neoplasm. So, if your oncologist is prescribing a drug prophylactically, but there is no evidence of a malignancy, you can use a history code as a part of justifying the medical necessity of the treatment. For example, a family history code such as Z80.3 (Family history of malignant neoplasm of breast) would be especially appropriate in this situation if a patient with a family history of a mutated breast cancer (BRCA) gene was taking a drug like tamoxifen to prevent breast cancer.

Coding caution: Make sure you review your oncologist’s notes before assigning a Z85.- or Z86.00 codes in situations like this. You’ll need to make sure the patient is completely free of any cancer, and that the treatment is not being directed to a specific anatomic site.

Myth 3: If You Only Have a History Diagnosis, You Can Use it As a Primary Diagnosis

This myth is incorrect, and going back over the first myth and guideline I.C.21.c.4 will tell you why. You must code the reason for the encounter first, and the history code second. So, if a personal history of cancer is the only diagnosis you have, you’ll code the reason for the encounter — usually Z08 or Z09 when the encounter is a follow-up — followed by the history code.

Similarly, if the only diagnosis information you have is for a family history, then you will code for the encounter first, using a code from Z12.- (Encounter for screening for malignant neoplasms) for example, followed by a Z80.- code.

Myth 4: You Can Use a Z85 Code for Former Sites of Primary and Secondary Malignancies

This myth is completely false. If you go back to guideline I.C.2.m, you’ll find an instruction to use Z85.89 (Personal history of malignant neoplasm of other organs and systems) “for the former site(s) of either a primary or secondary malignancy,” and to only assign Z85.0–Z85.85 “for the former site of a primary malignancy, not the site of a secondary malignancy.”

Myth 5: You Should Always Use a Family History Code

This myth is somewhat of a gray area. ICD-10-CM guideline I.C.21.c.4, which offers guidance for using history codes, has this to say: “Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.” This suggests you should use a family history code whenever the patient’s family history indicates they have a genetic predisposition to a specific condition.