Oncology & Hematology Coding Alert

Question: A patient who received treatment from our provider for endometrial cancer two years ago returned to our practice, and our provider documented recurrent endometrial adenocarcinoma to the vaginal cuff, stage 1A. Do I document this as metastatic process of endometrial to the vaginal cuff (C79.82) given that it’s recurring at the vaginal cuff, or should it be documented as endometrial cancer (C54.1)?

AAPC Forum Participant

Answer: Even though the provider has documented the cancer as recurrent, you cannot code the condition as metastatic for a number of reasons. First, the condition has not been labeled as such in the report. Second, in the absence of the condition being classified as metastatic, you should consider the condition as primary and code it as such. Additionally, the documentation notes that the cancer is stage 1A, which suggests that it has not spread to other sites and, again, is a primary tumor.

So, as this looks to be a new primary cancer, C54.1 (Malignant neoplasm of endometrium) would seem to be a more appropriate code choice than C79.82 (Secondary malignant neoplasm of genital organs). However, this would be a good opportunity to query your oncologist, surgeon, or pathologist to arrive at a more definitive answer.