June 1, 2017
Accurate medical record documentation and claims data are critical to continuity of care for patients fighting cancer. Here's how to prevent two common documentation errors related to the care of patients with breast, cervical, and/or colorectal cancer, or a history of these conditions.
Providers and coders often ask these two questions, “When should I code a neoplasm as current vs historical?” and “How do I code a malignancy that has been excised?”
To code a neoplasm as current, there must be evidence of active treatment or status in the provider's documentation. Examples include:
- Current treatment as indicated by anti-neoplasm drug therapy or chemo/radiation therapies
- Refusal of treatment by patient or watchful waiting
- Physician's pathology revealing cancer
If a malignancy has been excised, it doesn't automatically mean that you should use a “history of” code. For example, if a patient still receives treatment directed to the site of excised cancer, code it as current until treatment is completed. If there is no further treatment documented, code it as historical.
When an excision is documented, make sure it indicates if an organ was removed completely or partially. For example, document whether a mastectomy was a unilateral or bilateral mastectomy, and whether a hysterectomy is with or without remaining cervix.
For more information about best practices in documentation and coding, contact ProviderEngagementTeam@Premera.com or view our tools and trainings.