November 1, 2018
During medical record audits, one of the most common coding errors identified is cancer diagnoses. Diagnosing and treating patients with cancers is a very complicated process. Documenting and coding these conditions is also complex.
These are common questions that providers have regarding cancer documentation and coding:
- When should I switch from coding my patient as having active cancer to a personal history of cancer?
- Should cancer always be coded as historical if it’s surgically removed?
- What diagnosis codes would I use for patient with a bilateral mastectomy and is on Tamoxifen?
Learn how to avoid common documentation and coding errors by understanding when to document a cancer as active versus historical. Misinterpreted documentation often leads to submission of incorrect cancer codes. These diagnoses become part of your patients’ permanent diagnostic records.
For more information about documentation and coding chronic or complex condition, email your Provider Clinical Consultant at providerclinicalconsulting@premera.com.