06/17/2025

Oncologists Can’t Afford to Incorrectly Document Comorbidities and Complications

Accurate documentation of the comorbidities and complications of patients with cancer does more than just guide clinical care and support reimbursement, it directly informs the medical codes that drive large-scale cancer research and population health insights. When documentation is incomplete or unclear, the ripple effects extend far beyond the individual patient. Here are some practical strategies to ensure that your records translate into meaningful data to help improve patient care and research.

Collecting and Reporting Data on Comorbidities Matters, Can Be Challenging
Documentation of patients’ comorbidities in the medical record supports reimbursement claims for higher-paid Evaluation and Management (E/M) codes and for separate E/M CPT codes on the same day as treatment, as indicated by modifier 25. In short, they corroborate the severity and complexity of a patient’s illness, which speaks to medical necessity.

Oncologists face multiple challenges in documenting comorbidities, explained Jay F. Piccirillo, MD, an otolaryngologist, clinical epidemiologist, and health services researcher practicing at Washington University in St. Louis. “Many symptoms of comorbid conditions can overlap with those of cancer, making accurate attribution difficult,” he said.

Dr. Piccirillo offered a list of symptoms that are common to both cancer and other conditions:

• Chronic cough: This could be a symptom of lung cancer or a manifestation of chronic obstructive pulmonary disease or asthma.
• Fatigue: This is a common symptom in patients with cancer but can also be a result of depression or thyroid disorders.
• Unexplained weight loss: Although this can be a sign of malignancies, such as pancreatic or gastrointestinal cancer, it can also be attributed to uncontrolled diabetes or hyperthyroidism.
• Chronic pain: Bone pain might be a sign of metastatic cancer, but could also result from arthritis or osteoporosis.
• Shortness of breath: This could indicate lung cancer or be a symptom of heart failure or pulmonary embolism.
• Abdominal pain: This could suggest gastrointestinal cancers but also could be a result of peptic ulcer disease or irritable bowel syndrome.
• Headaches: Although these might indicate a brain tumor, they can also occur because of migraines or tension headaches.

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