Cancer Coding Requirements

As you are likely aware, the Centers for Medicare and Medicaid Services (CMS) has been conducting aggressive audits of Medicare Advantage plans as part of its effort to “crush fraud, waste, and abuse across all federal healthcare programs.” Unfortunately, our reviews have revealed several cancers that are not actively undergoing treatment coded as active. While there is no opportunity to go back in time, moving forward is an opportunity for improvement. 

According to CMS guidelines and related coding resources, active cancer is defined as a malignancy that is currently being treated, managed, or has not yet been fully eradicated. This usually refers to a status where the patient is undergoing active, curative, or palliative treatment, rather than just surveillance. 

Key Requirements for Coding an Active Cancer

• Active Treatment: CMS defines this as a malignancy that is currently being treated managed or is undergoing an active workup. The patient is receiving, or has been prescribed, active therapeutic treatment, including chemotherapy, radiation therapy, surgery, immunotherapy, or targeted hormone therapy. 
• Clinical Documentation: The provider must clearly document the assessment, evaluation, and plan for the cancer in the medical record. 
• Unresponsive/Refused: Active codes (ICD–10–CM codes for malignant neoplasms) are used if the cancer is not responding to treatment, or if the patient has refused. 
• Watchful Waiting: Used when the treatment plan is “watchful waiting” or active surveillance rather than “history of.” 
• Persistent Disease: The cancer is present, or has recurred, and is not yet in remission. 
• Specificity: Codes must be selected to the highest level of specificity (e.g., anatomical site, staging).  

Distinction from “History of” Cancer

ACTIVE: Requires active treatment (e.g., C61 for active prostate cancer) 

HISTORY OF: The cancer was surgically removed or eradicated, no further treatment is directed at that site, and there is no evidence of existing disease. These cases use Z codes (e.g., Z85.3 for personal history of breast cancer). 

Exceptions and Specific Scenarios

• Adjuvant Therapy: If a patient is taking medication (like Tamoxifen or Lupron) to treat a cancer that was removed, it is considered active. If it is taken for prophylactic/ preventative purposes, it may be considered history of. 
• Hematological Malignancies: Leukemia and multiple myeloma are often treated as “in remission” rather than “history of” once the treatment is complete. 
• Surveillance: Routine, long-term surveillance by a specialist to monitor recurrence does not qualify a cancer as active. 

Key Reminders for CODERS

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.