Accurate diagnostic coding plays a crucial role in identifying the disease burden of the patient population, determining a risk adjusted cost of care score, improving revenue and more. The new Coding Corner will provide tips to help improve diagnostic coding.
coding guidelines* state in Section I.C.2.m.
“When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.”
“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
, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.”
Documentation must clearly indicate that the cancer was either not treated or is being actively treated, including with adjunct therapy. Forms of active treatment include:
- Current hormonal therapy
- Active surveillance
- Refusal of or is too frail for treatment
The exception to the rules occurs when coding multiple myeloma and leukemia. These diagnoses have “in remission” codes that physicians should use once treatment is completed and the patient achieves remission. For example, when a patient diagnosed with acute myeloblastic leukemia, treated with chemotherapy, and successfully achieved remission returns to the office for a visit and has no evidence of recurrence, the code for acute myeloblastic leukemia in remission (
) should be used.
Ethica provides hands on, face to face assistance to helps practices with accurate diagnostic coding. Visit
or call (586) 498-3587 to learn more and to schedule a consultation.