Wiki Coding active cancer vs. history of cancer

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Carla Goodell

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My physician (an extremely brilliant pulmonologist) is stating that if his patient had lung cancer that was treated, he considers that cancer "active" until 5 years have passed since the treatment and he would like to use a "current" lung cancer diagnosis. He does not consider the cancer eradicated until the patient shows no evidence of disease for 5 years post-treatment and he feels that other physicians would agree. ICD-10 Coding Guidelines state that "Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment but that has the potential for recurrence, and therefore may require continued monitoring". I would prefer to use a "history of" diagnosis because the patient is not receiving active treatment, just monitoring. Is there a right or wrong answer here?
 
A doctor may say a patient has cancer for 5 years after it was removed but this medical concept doesn't carry-over to ICD. The ICD guideline has not changed from ICD-9. You can find yourself in lots of trouble for ignoring the guidelines.
 
I would disagree - if the physician states in the record that it is an active disease, then the history code is not appropriate. The guidelines say that the history code is for "a condition that no longer exists". It's really up to the physician to make the determination that it no longer exists. If they're not willing to declare the patient cancer-free, then it's still an active and valid diagnosis.
 
However if it is documented as no evidence of disease and has no current treatment, then it is history. I do agree though that if the provider documents active disease then that is how it is to be coded.
 
I don't agree, I-10 Guidelines determine when a person is considered to be a history of. Physician cannot override ICD guidelines.

This issue comes up a lot with HIV vs AIDS. Some physicians believe because they can convert a person back to HIV status because they successfully treated their AIDS related conditions and its in remission, in the end of the case it doesn't really matter. Patient is still considered a B20 by ICD guidelines.
 
If the patient is not being actively treated and the cancer has been resected/treated it would not be clinically backed by coding an active disease without evidence of the disease being present. This would just be follow up care after treatment and monitoring of a treated condition. The biggest key to the neoplasm guidelines is actively treated. Follow ups after the complement of treatment with no clinical evidence of the presence of the disease would code to a history code. Now, if there is evidence that the treatment did not work then yes it would be appropriate to use the neoplasm code as the condition is clinically present or if a recurrence occurs that it is active again.

Coding is no longer as simple as just coding what the doctor says as it once was. Now diagnosis must be back up by clinical evidence and without this evidence a company will deny claims. This can lead to messy denials based on no clinical evidence in the case of cancer being present. Even doctors clinical judgment can be challenged and insurance companies use physicians to review documentation for appropriate clinical presence of a diagnosis. Remember what every coder was taught when you were learning to code, "If it isn't documented you cannot code it" well this now includes things to back up the diagnosis as well as procedures and not just the right buzz words for the code itself. From the guidelines "A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures." It is not just the physician's responsibility it is also the coder's that everything is complete and accurate so that things are done appropriately.

You cannot ignore the guidelines. The guidelines are very clear. Once the neoplasm has been excised or destroyed and is no longer being actively treated it is coded to a history code. Even though the patient may not be deemed "cancer free" from a medical standpoint for 5 years the coding guidelines do not capture this information and it would be inappropriate to code it as an active cancer because it does not met the standards of the guidelines. I know your physician may not like it but it is the guidelines.

This is something many physicians have a hard time when it comes to coding. Their diagnosis may not translate to a code that looks right to them however coding is based on rules and strict guidelines that must be followed. Blatantly ignoring guidelines can actually land you in a sticky situation especially if you bill to the Federal Government. My advice is explain that while he is absolutely correct on the medical side of cancer it is not following the guidelines of ICD-10-CM and it would be willfully ignoring them and that the guidelines have to be followed.

I say this as someone who has dealt with all sides of this. I have been involved with denials for lack of clinical evidence and dealing with the CDI and auditing side as well as working for a government payer doing audits of documentation and coding with physicians reviewing the clinical evidence, I cannot stress enough that you follow the guidelines and make sure what you are coding is in fact backed up by the documentation.
 
The coder does not get to determine the diagnosis, they get to determine only the code that goes to the diagnosis documented. If the provider documents the diagnosis as lung cancer, then this is what must be cod d. If the provider documents as lung cancer with no current evidence of disease and no current treatment, then the coder must the diagnosis as history of cancer regardless of the code selected by the provider. A coder cannot decide that documentation of active cancer is actually history.
 
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