Accuracy in documentation: documenting cancer — history vs. current condition

Documenting the history of cancer versus a current condition of cancer can be challenging for care providers. There are several considerations a care provider must consider when documenting the history of cancer versus the evaluation and treatment of cancer as a current condition.*

History of cancer

It is recommended to use a history of cancer code (Z85.-) when:

• Malignancy has been excised and no further treatment is directed at that site (such as radiation, chemotherapy, additional surgery).
• Routine follow-up care (surveillance) with oncology is required.

Current diagnosis/treatment of cancer:

• Documented confirmed cancer prior to the start of treatment
• Active treatment for cancer and/or related symptoms (examples include chemotherapy, radiation, and hormone therapy)
• Watchful waiting to determine if or when the treatment should begin
• The patient and care provider decide to not treat the cancer (for example, palliative care or hospice).
• Current treatment is being temporarily stopped for the following reasons: to determine appropriate/alternate treatment, to allow patient to rest from effects of treatment, or for the transfer of care where treatment is to be continued by another care provider
• Requires monitoring, evaluation, assessment, and treatment (MEAT) documented in the record to code as active cancer

Documentation of cancer — best practices:

• It is not recommended to document “history of neoplasm” or “no evidence of disease” (NED) if the neoplasm is still being actively treated, even if it has been excised. Instead, it is recommended to document the continuum of care, noting what has been done and what is left to do.
• History of neoplasm and NED indicates an eradication of the condition and a complete cure at the site and would result in a history of malignant neoplasm code (Z85.-).
• If a selective estrogen receptor modulator (SERM) like tamoxifen is prescribed, document whether the medication is treatment for active cancer or for prophylaxis against the cancer’s return:
  • Active treatment would result in an active neoplasm code.
  • Prophylaxis would result in a history of cancer code.