Determining whether a patient’s cancer should be classified as active or historical can be complex, and the implications for documentation and coding are significant. Many oncologists face uncertainty in this area, but practical strategies and clear guidelines can help resolve the confusion.
This is a confusing topic for providers, particularly when medications are involved, said Yaron Gesthalter, MD, an interventional pulmonologist practicing in the Thoracic Oncology Group at the University of California San Francisco.
"I am not sure that doctors [fully understand] the concept", agreed coding consultant, Betsy Nicoletti. In essence, if a patient is still receiving treatment for cancer, the diagnosis must be documented as active, using a malignant neoplasm code. However, if treatment has concluded and there is no evidence of disease, the appropriate designation is a personal history of neoplasm (Z85.-). It is the oncologist’s documentation that determines how the diagnosis is coded, making clarity and accuracy critical for both clinical and billing purposes, Nicoletti explained to Oncology News Central.