University HealthCare Alliance

December 04, 2019

Optum Insider | Correctly Reporting Cancer Diagnoses

Current Cancer vs History of Cancer

Correct reporting of a diagnosis of cancer requires the determination and documentation of whether the patient’s cancer has been eradicated or is currently being treated. ICD-10-CM greatly increases the specificity of the neoplasm code classifications.

Many neoplasm conditions have either been given unique classifications or have been further specified by type, anatomic site and laterality.  Neoplasms are listed in the ICD-10-CM Neoplasm Table by type and anatomical site. For each site, there are six possible code categories situated within columns according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior or of unspecified nature. The description of the neoplasm will often indicate which of the six columns is appropriate; for example, malignant melanoma of the skin, benign fibroadenoma of breast, carcinoma in situ of cervix uteri.

If neoplasms are documented by the histological term, that term should be referenced in the ICD-10-CM Alphabetic Index for each variety, rather than going immediately to the Neoplasm Table.

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