This blog was updated for ICD-10-CM. Read it here.
One of the most common provider charting errors occurs in the area of cancer diagnoses. Practitioners routinely document and code cancers when the patient’s disease has been treated and is no longer evident. For risk adjusted practices, this means the patient’s risk score – and the practice’s reimbursement – are inflated, which can lead to positive (which are a bad thing) audit findings and loss of capitation.
The coding guidelines for cancer state that “When the primary malignancy has been excised, no further treatment is directed to the site & there is no evidence of an existing malignancy,” the clinician must document ‘history of XYZ cancer’ and not the cancer diagnosis. [Source: International Classification of Diseases, 9th Edition, 2011] Cancer histories are coded from the v10 category of codes (Personal history of malignant neoplasm) and are not weighted diagnoses under risk adjustment. For MRA, it’s important to remember that funding losses are retroactive, so the impact of this error to the provider can be quite significant.
The rule of thumb for a cancer diagnosis is the presence of an active condition: either one that is receiving treatment, or one that has been diagnosed via objective means and for which treatment is not pursued at the time (for any reason).
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