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The #1 Error in RA Coding

Jun 5, 2024 | News

Stay out of harm’s way when it comes to risk adjustment compliance.  Granite GRC Consulting presents a series of monthly articles for the Pennsylvania Medical Society’s DOSE newsletter.  Visit https://www.pamedsoc.org/membership/partners to learn more.

The number one error for risk adjustment documentation and coding, based on dozens of OIG audits released over the past two years, is coding for neoplasms. It is an easy problem to understand.

For providers, the vigilance required to monitor and counsel for cancer recurrence is a process that lasts for years after surgery, chemotherapy, and radiation therapy has been completed. This takes resources. Most providers continue to use an active cancer diagnosis during this period of surveillance.

However, the WHO and CMS through ICD-10-CM guidelines, define cancer a little differently. For them, once the cancer has been removed, and treatment completed, the cancer is history. This requires a change in mindset for providers, and a change in word choice for documentation. According to ICD-10-CM guideline I.C.2.m.:

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, 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.

Therefore, after a double mastectomy, if a SERM is prescribed, providers should note whether the SERM, for example, tamoxifen, is being used to treat existing cancer or to prevent its return after therapeutic intervention has been completed. Providers should simply state the treatment is for prophylaxis or for therapy. If the cancer has spread to the bone, report the bone metastases as a secondary cancer, and a history of breast cancer to identify its origin.

Tumors should be specified as benign, carcinoma in situ, primary, secondary, or has having uncertain or unspecified behavior. “Unspecified behavior” in ICD-10-CM is reserved for neoplasms that have not been analyzed, while uncertain behavior identifies those tumors that have been examined microscopically, but their nature is not yet discernable.

The words used in documentation will direct coders and auditors on the patient’s cancer status. Consider what the patient has been told: If the patient has been informed there is no evidence of disease and has completed treatment, the provider should not be reporting an active cancer code.

For solid tumors, there is never “remission” in ICD-10-CM, only active or history.  To use “remission” for solid tumors in documentation is to invite a query, as this cannot be codified. Liquid cancers including multiple myeloma and hematopoietic cancers like leukemia, do have specific codes for remission, and status should be stated. For these tumors, cite status as not having achieved remission, in remission, in relapse, or history of (usually only seen in pediatrics). These liquid tumors, by their very definition, are systemic and therefore should never be documented as metastatic.

Understanding the nuances involved in coding neoplasms can help you avoid errors.   What coding and documentation challenges are you facing?  Contact Sheri Poe Bernard at Granite GRC: spb@granitegrcconsulting.com or call (717) 556-1090.

Written by Sheri Poe Bernard, CRC, CPC, CDEO, CCS-P, Director, Risk Adjustment Assessment and Compliance.  Granite GRC can help navigate your toughest risk adjustment challenges.  Contact us at info@granitegrcconsulting.com, or call (717) 556-1090.