Work with providers to ensure they’re capturing conditions and complications affecting the management of their oncology patients.
Oncology coding may seem a bit convoluted at first but given the prevalence of cancer and the major impacts it has on society, it’s crucial that medical coders understand the disease itself, as well as how comorbidities may affect the cancer and its management, explained Lee Williams, MBA, RHIA, CPC, CCS, CCDS, CPCO, CEMC, CHONC, CRC, at HEALTHCON 2021. This insight will facilitate coders’ ability to work closely with providers to ensure thorough documentation, which will aid in proper code selection and accurate depiction of the severity of a patient’s condition and the associated level of risk.
According to projections, there will be “just under 2 million new cases of patients diagnosed with cancer this year,” Williams said; and because the pandemic has caused delays in accessing healthcare, “organizations are quite worried and looking into the fact that we are probably going to have a high volume of undiagnosed new cases, or at least cases that get diagnosed a little later than what we would like to see.”
To help coders prepare for the likely uptick in volume many oncology practices will experience, Williams broke down and demystified oncology documentation and coding in her presentation “The Ins and Outs of Neoplasm Coding With Comorbidities.” Here’s a recap of that session.
Understand the Basics
Before delving into coding for neoplasms, Williams briefly reviewed some basic facts and statistics. Cancer — defined as a group of diseases characterized by the uncontrolled growth and spread of abnormal cells — is the second leading cause of death in the United States and is projected to kill approximately 608,570 Americans this year alone. The good news is that with the help of new drugs and immunotherapies, nearly 16.9 million Americans with a history of cancer were alive on Jan. 1, 2021. In other words, thanks to advancements in technology, “even though people are still succumbing to this disease every year … more and more people are actually beating the disease,” she explained.
The Devil Is in the Details
“When we are documenting or reviewing the medical record and trying to assign codes, it’s important to determine the type of cancer that we’re coding. And sometimes it’s difficult to do so because our providers don’t give us the documentation required,” said Williams. So, any time you are coding, make sure to always have supplemental documentation, such as a pathology report, that confirms the growth is truly cancer and details the exact type of cancer present.
She went on to say that when you’re reviewing these reports, it’s helpful to be familiar with the characteristics of and specific terminology associated with benign and malignant neoplasms. As you read through medical records and pathology reports, look for terms such as adenoma, fibroma, nevi, and lipoma, which indicate non-cancerous growths. These types of benign tumors do not invade surrounding tissues and may be treated with surgical removal, if needed. Alternatively, malignant tumors, which are formed from abnormal cells that divide uncontrollably, invade nearby tissues and are capable of spreading. In addition to surgical removal, cancerous neoplasms may be treated with adjunct therapy, which may include chemotherapy, immunotherapy, and/or radiation.
Williams emphasized again that defining the cancer is imperative when coding neoplasms. Doing so hinges on providers being specific in their documentation and coders having the findings from a biopsy or other pathological report available for reference. To select the correct code, coders must ascertain the following information about the neoplasm:
- Acuity: Acute, chronic, in remission, in relapse, history of; assign the latter, Z85 Personal history of malignant neoplasm, when “the cancer was treated and there is no evidence of disease.”
- Site: Specific location – body part/organ, tissue type.
- Cancer type: Carcinoma, lymphoma, melanoma, leukemia, Merkel cell, etc.
- Histologic behavior: Is the tumor benign, a primary/secondary malignancy, in-situ, unspecified, or uncertain? Regarding the latter, “the thing to keep in mind is you have to have a pathologist state that that mass or that tumor is of uncertain behavior. That designation cannot be made by the oncologist or another physician,” Williams pointed out. “The only time you can assign a code for uncertain behavior is if you have documentation from the pathologist saying it’s uncertain.”
Documentation Dictates Code Selection
The focus then turned to documentation and how it affects the code reported on the claim. First, you cannot assign a code for malignant neoplasm based on words such as “mass,” “lump,” or “cyst,” in the medical record. Those terms do not equate to a cancer diagnosis, Williams explained, which is why it’s crucial that you work with your providers to make sure they are using the correct terms and that their documentation is consistent.
Detailed provider documentation should consist of location, type, and metastatic site, if any, as well as any related conditions or complications resulting from either the neoplasm or the treatment. Furthermore, conditions related to the tumor should be documented in a manner that is linked to the neoplasm. She went on to state that terms such as growth, new growth, and tumor, without further specification, are coded to category D49- Neoplasms of unspecified behavior. But before you assign an unspecified code, it’s best to query the provider to get additional information or to clarify the patient’s condition.
Take, for example, anemia. Unspecified anemia is reported with D64.9. But if chemotherapy is what caused the patient to develop anemia, it should be documented as such, and the code reported would be D64.81 Anemia due to antineoplastic chemotherapy. Whereas if a patient is admitted with anemia secondary to the cancer, it should be documented as neoplasm-related anemia, which would change the code reported to D63.0 Anemia in neoplastic disease.
Also important for accurate coding is identifying the reason for the encounter or admission. Is the patient presenting for treatment of a complication, pain control, preventive services, post-treatment follow-up, or therapy? “Because if the patient is here, and the primary reason for the visit is chemotherapy, then we need to make sure we’re assigning the correct code on our claim form,” Williams explained. “The reason for the visit needs to be clearly stated so that your coding is correct.”
Don’t Discount Comorbidities and Complications
Don’t let your oncologists get stuck on oncological conditions, Williams advised. They also need to note chronic conditions (hypertension, kidney disease, diabetes, chronic obstructive pulmonary disease) and lifestyle choices (smoking, physical inactivity/obesity, insufficient diet, alcohol consumption) that either affect the cancer diagnosis or the treatments such as chemotherapy. Mention of such complexities “is really what’s going to support a higher E/M [evaluation and management], not necessarily that the patient has cancer,” she explained. It is extremely important that providers document any complications or comorbidities being factored into their medical decision making because documentation of related secondary conditions considered is “what’s really going to justify your E/M code with modifier 25 on chemo day.”
As demonstrated by “the changes to E/M codes for office visits, the emphasis really is on risk — the risk from the condition itself, as well as the risk from patient management or treatment,” said Williams, and “it’s up to the provider to document in a manner that’s going to support that higher-level code.” Work with your oncologists and emphasize that accurate and comprehensive documentation demonstrates both the severity of illness and the risk of mortality for that patient, which, in turn, “helps avoid denials and supports the patient encounter, as well as the admission and length of stay — it’s all about proving medical necessity.”
Work Together to Improve Outcomes
After discussing documentation pitfalls and going through some additional case scenarios, Williams circled back to the take-home message. “It is important that we all work together in order to get the providers to better capture those chronic conditions. And you do have to explain to them that it doesn’t necessarily increase the amount of time they’re spending on their documentation; because that is a barrier for them … just remind them that you are already doing the work mentally, you just need to transfer it to paper, transfer it to the documentation.”
Coders and clinical documentation improvement specialists must work together to “educate the provider on why the documentation is important and what is the impact on the patient.” Have a conversation about chronic conditions and how they impact patient management, and “work with them in terms of having them transfer it to the documentation … remind them just how it helps with the E/M leveling.” Because, as always, quality patient care, appropriate code selection, and accurate data collection hinge on comprehensive medical record documentation.
Practice With These Coding Examples
- Patient presents with metastatic bone cancer originating from the breast. She is post-mastectomy and has completed treatment for the primary site; no evidence of any remaining disease in the breast. Has complaints of bone pain and requests refill on pain meds.
G89.3 Neoplasm related pain (acute) (chronic)
C79.51 Secondary malignant neoplasm of bone
Z85.3 Personal history of malignant neoplasm of breast
Rationale: The cancer diagnosis is not always first listed. Since the reason for the encounter is pain, you’re going to list G89.3 as the primary diagnosis code, followed by the active code for secondary bone cancer. The personal history of breast cancer is reported last. A “history of” code is reported because the breast cancer has been treated and there is no evidence of active disease.
- Patient presents for C1D1 (cycle one, day one) of chemotherapy for a neoplasm of the stomach.
Z51.11 Encounter for antineoplastic chemotherapy
C16.9 Malignant neoplasm of stomach, unspecified
Rationale: Since the patient presents for treatment only, you’re going to assign Z51.11 for the chemo encounter first, followed by the unspecified code for the stomach cancer since we don’t have any information as to the specific site.
Learn more: Sign in to your My AAPC account and watch part of the HEALTHCON 2021 session where Lee Williams, MBA, RHIA, CPC, CCS, CCDS, CPCO, CEMC, CHONC, CRC, reviews two additional case scenarios, explaining which codes are correct and why.