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Documentation for Neoplasm Diagnosis

Date:
March 26, 2021

Accurate coding and documentation can tell us if your patient has active or past, benign or malignant neoplasm – important distinctions for your reimbursement and our records. Using the right ICD-10 codes (supported by documentation) for neoplasm diagnoses helps make sure you get paid correctly and may reduce the need for future medical record requests.

When submitting a claim for neoplasm, documentation should specify if the neoplasm is:

  • Benign
  • Carcinoma In-situ
  • Carcinoma Malignant primary
  • Carcinoma Malignant secondary
  • Uncertain behavior

If the neoplasm is malignant, documentation should also include if it is metastatic.

Resolved Malignant Neoplasms

If a malignancy is excised without a need for further treatment (chemotherapy, radiation, etc.), the active cancer code is no longer applicable. In this case, you should use one of the appropriate Z85.X ICD-10 codes to indicate “personal history of malignant neoplasm.”

Adjuvant Therapy

Document whether adjuvant therapy is being used for treatment or for prophylactic purposes. When used prophylactically, don’t code for active cancer.

Click here for more information on neoplasm documentation and ICD-10 codes.

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