Oncology & Hematology Coding Alert

Question: Can a radiology oncology practice use a “history of” code when a patient has no evidence of disease (NED) after treatment is complete? One of our providers says we should use an active diagnosis cancer code for five years after NED, believing that coding a patient with a history code would lead to the practice not being paid “as radiology oncology actively treats patients with cancer.”

AAPC Forum Participant

Answer: Recent guidance from the Society of Gynecologic Oncology (SGO) sheds light on this thorny issue. The SGO notes that the five-year cutoff for using primary cancer codes such as C56.- (Malignant neoplasm of ovary) is no longer prevailing wisdom. According to Section I.C.2.m. of the ICD-10-CM official coding guidelines, “When a primary malignancy has been previously excised or eradicated from its site, 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, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.” (Source: CMS ICD-10-CM Guidance www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf).

This is the guidance recognized for patients who are on surveillance after treatment has been completed. “For patients on treatment, including maintenance, the primary cancer code should be used” (Source: 157slyoyo4y17zpa538hczs1-wpengine.netdna-ssl.com/wp-content/uploads/2020/04/ SGO-2021-Coding-Question-Library-Update-Project_v3.pdf).

So, if your practice is still seeing the patient for evaluation and management (E/M), but your practice is no longer treating the patient because the patient’s status is NED, you will still get paid for the surveillance if you use codes from Z51.- (Encounter for other aftercare and medical care) and Z85.- (Personal history of malignant neoplasm). And if the patient is still receiving treatment, even if it’s not necessarily radiation, you would use an active cancer code.