ICD-10-CM Diagnosis Code Z51.1 Encounter for antineoplastic chemotherapy and immunotherapy encounter for chemotherapy and immunotherapy for nonneoplastic condition - code to condition ICD-10-CM Diagnosis Code T80.810A [convert to ICD-9-CM]
H/o: chemotherapy; History of anti-cancer chemotherapy; History of antineoplastic chemotherapy; History of chemotherapy ICD-10-CM Diagnosis Code D61.810 [convert to ICD-9-CM] Antineoplastic chemotherapy induced pancytopenia
Agranulocytosis due to cancer chemotherapy; Chemotherapy-induced neutropenia; Neutropenia due to chemotherapy; underlying neoplasm; code for adverse effect, if applicable, to identify drug (T45.1X5) ICD-10-CM Diagnosis Code T80.810S [convert to ICD-9-CM] Extravasation of vesicant antineoplastic chemotherapy, sequela
Current: Cancer is coded as current if the record clearly states active treatment is for the purpose of curing or palliating cancer, or states cancer is present but unresponsive to treatment; the current treatment plan is observation or watchful waiting; or the patient refused treatment.
Personal history of antineoplastic chemotherapy Z92. 21 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z92. 21 became effective on October 1, 2021.
The ICD-10 code for an evaluation prior to chemotherapy is Z01. 818 (encounter for examinations prior to antineoplastic chemotherapy). Z51.
When a patient's cancer is successfully treated and there is no evidence of the disease and the patient is no longer receiving treatment, use Z85, “Personal history of malignant neoplasm.” Update the problem list and use this history code for surveillance visits and annual exams.
Persons encountering health services in other specified circumstancesZ76. 89 is a valid ICD-10-CM diagnosis code meaning 'Persons encountering health services in other specified circumstances'.
Code 96413 (chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) would be used to report the first 90 minutes of the infusion.
Chemotherapy Administration and Other Highly Complex Drug or Highly Complex Biologic Agent Administration CPT® Code range 96401- 96549.
Personal history of malignant neoplasm, unspecified Z85. 9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z85. 9 became effective on October 1, 2021.
In-active neoplasm or cancer is coded when a patient is no longer receiving treatment for cancer and the cancer is in remission by using the V “history of” code (“Z” code for ICD-10).
Cancer is considered historical when: • The cancer was successfully treated and the patient isn't receiving treatment. The cancer was excised or eradicated and there's no evidence of recurrence and further treatment isn't needed. The patient had cancer and is coming back for surveillance of recurrence.
ICD-10 code Z51. 81 for Encounter for therapeutic drug level monitoring is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
The code Z76. 89 describes a circumstance which influences the patient's health status but not a current illness or injury. The code is unacceptable as a principal diagnosis.
Z71.2 as principal diagnosis According to the tabular index, a symbol next to the code indicates that it is an unacceptable principal diagnosis per Medicare code edits. This applies for outpatient and inpatient care.
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.
A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion '), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.
The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.
Chapter 2 of the ICD-10-CM contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms , such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm, it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary ( metastatic) sites should also be determined.
When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1 -, malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm. Encounter for complication associated with a neoplasm.
When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only , the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present .
The 2022 edition of ICD-10-CM Z92.29 became effective on October 1, 2021.
Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status
The 2021 edition of ICD-10-CM Z92 became effective on October 1, 2020.
Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status
The 2022 edition of ICD-10-CM Z92 became effective on October 1, 2021.
A type 2 excludes note represents "not included here". A type 2 excludes note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When a type 2 excludes note appears under a code it is acceptable to use both the code ( Z92) and the excluded code together.
For more context, consider the meanings of “current” and “history of” (ICD-10-CM Official Guidelines for Coding and Reporting; Mayo Clinic; Medline Plus, National Cancer Institute):#N#Current: Cancer is coded as current if the record clearly states active treatment is for the purpose of curing or palliating cancer, or states cancer is present but unresponsive to treatment; the current treatment plan is observation or watchful waiting; or the patient refused treatment.#N#In Remission: The National Cancer Institute defines in remission as: “A decrease in or disappearance of signs or symptoms of cancer. Partial remission, some but not all signs and symptoms of cancer have disappeared. Complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body.”#N#Some providers say that aromatase inhibitors and tamoxifen therapy are applied during complete remission of invasive breast cancer to prevent the invasive cancer from recurring or distant metastasis. The cancer still may be in the body.#N#In remission generally is coded as current, as long as there is no contradictory information elsewhere in the record.#N#History of Cancer: The record describes cancer as historical or “history of” and/or the record states the current status of cancer is “cancer free,” “no evidence of disease,” “NED,” or any other language that indicates cancer is not current.#N#According to the National Cancer Institute, for breast cancer, the five-year survival rate for non-metastatic cancer is 80 percent. The thought is, if after five years the cancer isn’t back, the patient is “cancer free” (although cancer can reoccur after five years, it’s less likely). As coders, it’s important to follow the documentation as stated in the record. Don’t go by assumptions or averages.
According to the ICD-10 guidelines, (Section I.C.2.m):#N#When a primary malignancy has been excised but further treatment, such as additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is complete.#N#When a primary malignancy has been 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, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.#N#Section I.C.21.8 explains that when using a history code, such as Z85, we also must use Z08 Encounter for follow-up examination after completed treatment for a malignant neoplasm. This follow-up code implies the condition is no longer being actively treated and no longer exists. The guidelines state:#N#Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment.#N#A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code.#N#For example, a patient had colon cancer and is status post-surgery/chemo/radiation. The patient chart notes, “no evidence of disease” (NED). This is reported with follow-up code Z08, first, and history code Z85.038 Personal history of other malignant neoplasm of large intestine, second. The cancer has been removed and the patient’s treatment is finished.
This is an 86-year-old gentleman who underwent right hemiglossectomy with right supraomohyoid neck dissection on February 26, 2016. Postoperatively he states he is doing well and eating “everything that’s put in front of me”. He denies any difficulty with dysphagia.
History of Cancer: The record describes cancer as historical or “history of” and/or the record states the current status of cancer is “cancer free,” “no evidence of disease,” “NED,” or any other language that indicates cancer is not current. According to the National Cancer Institute, for breast cancer, the five-year survival rate ...
The fear is, history of will be seen as a less important diagnosis, which may affect relative value units . Providers argue that history of cancer follow-up visits require meaningful review, examinations, and discussions with the patients, plus significant screening and watching to see if the cancer returns.