Chapter 2: Neoplasms “Official Guidelines for Coding and Reporting” Clarifications: Current Malignancy vs Personal History, Primary or Secondary Site(s)November 8, 2018
Two seemingly small revisions and the addition of a paragraph were made to the Chapter 2: Neoplasms (C00-D49) “Official Guidelines for Coding and Reporting” (OCG), specifically
- C.2.d. Primary malignancy previously excised, and
- C.2.m. Current malignancy versus personal history of malignancy
These guideline revisions became effective October 1, 2018. The OCG are applicable to all health care settings unless otherwise indicated.
Three words that might easily be overlooked were added to each of the two guidelines referenced above; they are “at that site.”
The paragraph “Subcategories Z85.0-Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8-, maybe assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory,” was added to the second guideline.
After reviewing these guidelines and taking note of the revisions, now is the time to either confirm that you were correctly reporting codes for these diagnoses all along (great!), or begin correctly reporting these diagnoses codes going forward.
Let’s review the two guidelines.
I.C.2.d. Primary malignancy previously excised
The terms “at that site” was added in the first sentence to read “When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.”
To correctly apply this guideline, review the diagnosis to determine if it meets all of these criteria:
- The malignancy diagnosis refers to the primary site
- The primary malignancy has been previously excised or eradicated
- There is no further treatment directed to that site of the primary malignancy
- There is no evidence of any existing primary malignancy at that site
If all of these criteria are met,
- Report a code from category Z85.0 – Z85.7 (see the next guideline) and note it
- Codes from category Z85.0 – Z85.7 are reported as secondary codes only
Next, I.C.2.m. Current malignancy versus personal history of malignancy
For consistency with the previous guideline referenced above, the phrase “at that site” was added to first sentence of second paragraph in this guideline to read, “When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.”
Basically, these are the same instructions as in the previous guideline.
The paragraph addition “Subcategories Z85.0-Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8-, may be assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory,” contains new information to be applied going forward and boils down to
- Report a code from Z85.0-Z85.7 for the former site of a primary malignancy only
- Report a code from Z85.8- for the former site or sites of secondary malignancy
Finally, if a former primary malignancy site does not meet the description of any of the codes listed in Z85.0-Z85.7, report a code from Z85.8-.
For example, the diagnosis “history of malignant melanoma, primary” is not found in Z85.0-Z85.7, so the correct code to report is Z85.820, Personal history of malignant melanoma of skin. This code, as well as any code on the Z85.8 range, may be reported for either a primary or secondary history of malignancy.
As always, provider documentation is key to reporting the correct code or codes. Documentation must include this information and may be found in the patient’s history and physical (H&P).
- What site is primary and if it has been excised or eradicated, and if it is still under treatment
- What sites(s) are secondary and if they have been excised or eradicated and not under current treatment
A query may be needed if the provider documentation is not clear. Some facilities would not query for this type of documentation; check your internal policies and procedures.
Here are two examples of common case scenarios:
Example 1: A patient with history of primary malignancy of the right breast is status post left lumpectomy in 2016. Regular follow-up revealed a right upper lobe lung mass which was completely excised during an inpatient admission, requiring no additional treatment. The pathology report confirmed that the lung mass was a metastatic adenocarcinoma, primary breast. The provider documents “metastatic breast cancer, right upper lung lobe” as the final diagnosis. The coder determines the correct codes using the H&P and pathology report. The diagnoses codes for the encounter for the excision of the RUL metastatic adenocarcinoma are reported:
C78.01 Secondary malignant neoplasm of right lung
Z85.3 Personal history of malignant neoplasm of breast, for the former site of the malignancy, status post mastectomy with no further treatment or evidence of new or existing primary breast malignancy.
Example 2: The same patient is admitted in 2017 for treatment of an acute exacerbation of chronic obstructive pulmonary disease. Her history and physical report notes past surgical history of lumpectomy of right breast for and RUL lung excision for metastases to her lung. There has been no treatment or evidence of recurrent carcinoma in her breast or lung. The provider documents “AECOPD, hx of breast and lung adenocarcinoma” as the final diagnosis.
The coder reviews all of the documentation and determines which is the primary site or sites, and which is the secondary site or sites. Diagnoses codes for this encounter are reported;
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
Z85.3 Personal history of malignant neoplasm of breast. This code is reported for the history of the primary site.
Z85.89 Personal history of malignant neoplasm of other organs and systems. This code is reported for the secondary site, in this case the lung.
Do not be “tricked!” Z85.118 Personal history of other malignant neoplasm of bronchus and lung is not reported for the metastasis to the lung, s/p excision, because the lung was not a primary site. Codes in category Z85.0 – Z85.7 are reported for history of primary sites only, never for history of secondary, metastatic sites.
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