This document discusses guidelines for documenting cancer diagnoses for HCC coding purposes. It provides examples of information that should be documented, such as location of cancer, type of lesion, behavior (primary, metastatic, etc.), and treatment. Following documentation guidelines is key to accurate ICD-10 coding and ensuring the clinical picture is captured. History of cancer must also be clearly distinguished from active cancer to determine if a HCC code can be assigned.

2. Since This Is An Add On Course, The Prerequisite
Courses Should Be Done First. The Prerequisite
Course Will Give The Basic Information Needed To Be
Able To Get The More Pertinent And Detailed
Information Based On Different Diagnosis From This
Course.
Hierarchical Condition
Category Coding – CANCER

3. Documentation.
History of Cancer.
Wrap it up.
What do we know now?
Hierarchical Condition Category Coding – CANCER
This course is for HCC (hierarchical
condition category) Coding and Cancer

4. Hierarchical Condition Category Coding – CANCER
Understand the basics of HCC cancer coding, risk and how
it impacts clinicians.
Identify how to make HCC coding less confusing.
Gain a better understanding of documentation needed for
ICD-10 coding.
Learning Objectives

5. Hierarchical Condition Category Coding – CANCER
HCC - The Hierarchical Condition Category is a diagnosis grouping with
a single relative factor assigned to it for each model segment.
RAF - Risk Adjustment Factor.
PMH – Past Medical History.
M.E.A.T. – Monitored, Evaluated, Assessed, or Treated.
CMS – Centers for Medicare and Medicaid Services.
Acronyms

6. Documentation – The
Key to it All!

7. Documenting is the key to it all. We know this can be an intimidating task. By applying the
principles, you will learn in this short, but informative lesson, you can rest assured that
you will be on the right track!
Let’s Expand one's scope of thinking during patient evaluation to include specific
documentation verbiage for appropriate ICD-10 code. By using a clinical perspective to
simplify the documentation specificity required to generate valid 3-7 character codes
under ICD-10. Also, it’s important to recognize the importance of accurately documenting
any associated diagnoses or conditions that impact care of current condition, decision
making, treatment or management.
Documentation that supports the cancer diagnosis and will protect your practice and its
revenue.
Documentation – The Key to it All!

8. General Documentation and
coding guidelines are:
The documentation must support the code
selected and substantiate that proper coding
guidelines were followed.
Documentation Requirements for ICD-10-CM
Code capture.
CMS Ruling: Use of Problem Lists.

9. The documentation must
support the code selected
and substantiate that proper
coding guidelines were
followed
Chronic diseases treated on an ongoing basis may be coded
and reported as many times as the patient receives treatment
and care for the condition(s)(I ICD 10).
Code all documented conditions that coexist at the time of the
encounter/visit, and require or affect patient care, treatment or
management. Do not code conditions that were previously
treated and no longer exist. History codes (ICD-10:Z80-Z87)
personal and family history codes) may be used as secondary
codes if the historical condition or family history has an impact
on current care or influences treatment. (J ICD 10).

10. Documentation
Requirements for ICD-
10-CM Code capture
Under the official ICD-10-CM Coding Guidelines, a
diagnosis can only be coded when it is explicitly
spelled out in the medical record
All documentation used for coding must be specific
Super-bills, encounter forms and referrals are not
acceptable forms of documentation. CMS does not
recognize superbills as an extension of your
documentation. These forms are simply a billing tool to
capture services provided for a specific encounter.

11. Documentation
Requirements for ICD-
10-CM Code capture
For CMS’ risk adjustment data validation purposes, an
acceptable problem list must be comprehensive and
show evaluation and treatment for each condition that
relates to an ICD-9/ICD-10 code on the date of service.
It must be signed and dated by the physician or
physician extender (NP, PA).

12. Don’t forget your M.E.A.T.:
Monitor Evaluate Asses/Address Treat

13. Documentation – The Key to it All!
When you are dealing with patients who have cancer, it is important to understand how
to accurately document a cancer diagnosis. The surest way to document a cancer
diagnosis is by having all of the following information in the patient’s medical records,
and keeping consistent with the basic documentation guidelines already set out for you.
The first thing that you must document is the Location of the cancer.
Location – Anatomic part of the body – Where is the cancer located?.
When Documenting the location of the cancer, do
remember to add any overlapping site boundaries
and; any multiple non-contiguous sites in the
same location.

14. Document by type, site and metastases of neoplasm
Keep in mind, when documenting, what the ICD-10 code states, this will help you
when documenting. As you read the codes below, note the information you would
need to know to complete the code to it’s highest specificity some examples are:
C18. _ Malignant neoplasm of colon (EXCLUDES malignant carcinoids) Specify
site (cecum, appendix, ascending colon, hepatic flexure, transverse colon,
splenic flexure, descending colon, sigmoid, overlapping sites, or unspecified).
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph
nodes.
HCC 8 Metastatic Cancer and Acute Leukemia Is the highest weighted HCC,
approximate RAF of 2.6.
 Sickest patients, the most resources anticipated to be utilized.

15. Type of lesion
Histology or cell type if known

16. Behavior – document all that apply
Primary – cancer that arises from the cells found where the surgeon biopsies the
neoplasm.
Secondary/Metastatic – Cancer cells originated elsewhere and spread to this location.
Documentation should clearly indicate the primary cancer and location of metastasis.
In situ – Malignancy confined to the site of origin without invasion of neighboring tissues.
Malignant primary
Malignant secondary
Ca in situ
Document by type of neoplasm, site and metastases
Benign
Uncertain behavior (path report)
Unspecified
From: Index and Table of Neoplasms in 2017 ICD-10-CM code book.
If outpatient, can’t code diagnosis if documented as “possible”, “probable”, “consistent with”, “rule out”, or
differential dx. Outpatient “working diagnosis” is coded as signs or symptoms until diagnosis confirmed.

17. Treatment
Chemotherapy.
Radiation therapy.
Immunotherapy.
Surgical intervention.
Brachytherapy.
Patient declines or is unable
to have treatment.
What is being done to eradicate the cancer, is
it targeting the primary or secondary
malignancy, any associated complications.

18. Cancer
Document: Site of primary and metastatic cancer, if
known. Grade, stage, and morphology if available.
Note: pathology report required to confirm
morphology of surgical specimens, otherwise coded
as unspecified. Acute/Chronic / or in remission
status.
Leukemia, lymphoma, multiple myeloma- risk adjust
(HCC) indefinitely even if in remission if assessed
and documented in chart every year.
Update your medical record when more specific
diagnoses become available!

19. Cancer
Z08 Encounter for follow-up examination after
completed treatment for malignant neoplasm.
Z85.03_ Personal history of malignant neoplasm
of large intestine.
Surveillance after treatment is not active
treatment (i.e. colonoscopy after excision of
colon CA).
HCC 8 Metastatic Cancer and Acute Leukemia (RAF approx. +2.6).
HCC 27 End-Stage Liver Disease (approx. +1.1).
Lung and Other Severe Cancers (RAF approx. + 0.95).
Lymphoma and other Cancers (approx. + .68).
Medical conditions are hierarchically weighted within HCC
categories, here are some examples in descending order of
RAF values.

20. History of Cancer – just a
few other things!

21. History of Cancer - just a
few other things!
Almost all diagnosed ACTIVE cancers
are associated with hierarchical
condition category code (HCC).
However, “history of” cancer is not
associated with a HCC. So, it is
important that cancer is documented
and coding accurately following the
ICD-10 guidelines.

22. History of Cancer – just a few other things!
When diagnosing cancer, consider whether the cancer is active or the patient has a
history of cancer:
“Active” cancer – Indicates a current, active diagnosis of
cancer when any of the following exist:
 The patient has evidence of current disease.
The patient is receiving treatment for cancer. This includes
current or long term therapies.
The patient did not receive definitive treatment for their
malignancy.
“History of” cancer – The patient has successfully completed
treatment for malignancy, has no current treatment for the
condition and no evidence of the disease.

23. History of Cancer – just a few other things!
Beware of how PMH (past medical history) is used in documentation!
Cancer: Is it active, under treatment, in remission, or is it really PMH?
Active malignancy is HCC (excludes most skin CA and in-situ tumors except melanoma).
Document malignancy is active and address treatment, even if being treated by specialist.
Active treatment includes Tamoxifen or Lupron.
Malignancy is still active if cancer present but patient declines treatment or is being
observed (i.e. prostate CA).
If excised/eradicated and no further tx and no evidence of residual tumor, it is PMH (cured)
- not an HCC.

24. Wrap It up!

25. Wrap It up!
Document, document, document!
Make sure you mention, location, type of lesion, behavior and treatment when
coding for a cancer diagnosis.
This allows for you to get to the higher RAF values, also to capture that diagnosis
for a more appropriate reimbursement.
Update your medical record when more specific diagnoses become available!!!
Make sure you know when PMH should be coded and addressed..

26. What do we know now?