Table of Contents
To code breast cancer accurately using ICD-10, a coder must distinguish between primary active malignancy (C50) and secondary metastatic disease and personal history coding (Z85.3). Documentation detailing site, quadrant, laterality, and status of treatment is critical to proper sequencing and therefore, reimbursement. An error in classification can result in denial and leave the organization non-compliant. Adequate documentation from the provider and collaboration with the coder are key to accurate claims and risk adjustment reporting, as well as a strong oncology revenue cycle.
Specific ICD-10 coding for breast cancer is important for proper reimbursement, regulatory compliance, and maintaining the integrity of the clinical documentation. Coding for breast cancer demands differentiation of primary active malignancy, secondary (metastatic), and personal history of breast cancer. Each of these categories has its own sets of coding instructions, specific sequencing rules, and reimbursement considerations. Understanding these differences will ensure submissions are clean, denial risks are lowered, and clinical data remains accurate.
ICD-10-CM and Breast Cancer
The ICD-10-CM breast cancer codes are found in the C50 category which are codes for malignant neoplasm of the breast. Each code in this category, while in the same sub-category, will require a specific descriptor based on the precise anatomic location and the laterality of the condition. Coders will also need to determine a current status of the cancer; is it active, metastatic, or is it in historical condition that has been treated in full.
The most important thing to consider is the provider documentation that determines accurate classification. If the malignancy is still active and is undergoing treatment, then a C50 code is appropriate. If it has metastasized, then there are codes for additional secondary sites to be assigned. If a patient has been treated completely and no active disease remains, a personal history code will be required, and it will not be an active malignancy code.
ICD-10 Codes for Primary Breast Cancer
Active malignancies that develop in the breast tissue are known as primary breast cancers and are assigned as codes in the category C50. The ICD-10 system provides additional specificity for coding based on which breast and which sub-region the tumor is located.
Overview of Category C50
The C50 category encompasses malignant tumors of the breast and related structures, including the areola and nipple, central, upper inner, lower inner, upper outer, lower outer, and axillary tail. Each of these categories can further subdivide laterally (i.e., right, left, and bilateral or unspecified).
Site-Specific Coding
Coders can select the greatest specificity of code if the documentation contains sufficient detail; for example, malignancies in the upper outer breast and lower inner breast are coded differently. In cases where a breast tumor extends into several quadrants, and the exact origin of the tumor is not known, one should select the code for overlapping sites. Site unspecified codes should be avoided, as claims will often be denied for lack of detail.
Laterality Requirements
In breast cancer coding, laterality is an essential coding component. ICD-10 commercial breast cancer coding varies based on notated malignancy on the right breast or left breast. If notated laterality is not documented, coders have to code to the unspecified option, which increases the probability of the claim being denied or an audit occurring. Laterality has to be documented to substantiate quality of data and reimbursement claims.
Requirements for Documentation of Primary Breast Cancer
Proper coding of primary breast cancer requires complete documentation. The tumor’s anatomy, laterality, and the status of the disease must be described by the provider.
Site and Quadrant Location
When documenting possible tumor sites and quadrants, a provider statement is required. Specific anatomical reference increases precision in the assigned ICD-10 code and minimizes the use of unspecified options.
Laterality and Male or Female
Documentation is required to indicate if the left or right breast is affected by the cancer. Although breast cancer affects primarily females, male breast cancer exists and must be coded similarly under the same C50 structure. Documentation of gender clearly assists in the accurate processing of claims and in epidemiological surveillance.
Histological Type and Stage
Although the C50 code remains unchanged with histological type and cancer staging, they do represent significance regarding the medical necessity and treatment operational plans. Notations of histological findings such as invasive ductal carcinoma or invasive lobular carcinoma enhance the clinical documentation and strengthen the case for the oncology services to be billed to the payers.
Secondary Breast Cancer
Secondary breast cancer is defined as the cancer that has metastasized from the breast to any other organ or the other way around, that is the migration of the cancer from an alternate primary site to the breast. For metastatic disease coding, considerable care is needed for the sequence and the location of both primary and secondary locations.
Coding Metastasis from Breast to Other Sites
In the case of breast cancer that has metastasized to other organs like the bones, liver, lungs, or the brain, it is the duty of the coders to record both the code of primary breast cancer from the C50 category and the relevant code for secondary malignant neoplasms from the C77-C79 categories. The existence of metastasis does not mean that the primary site report is optional, nor does it mean that it becomes unnecessary if the primary site is still active. Both codes are needed to paint an accurate representation of the case.
Guidelines for Sequencing
The sequencing of codes will depend on the purpose of the encounter. For example, if the treatment is aimed at the metastatic sites, the secondary malignancy code may be sequenced first, and then the primary breast cancer code may follow. If the encounter is aimed at the treatment of the primary tumor, the code for C50 is to be listed first. Documenting the intended treatment helps with the sequencing of codes.
Breast as a Secondary Site
There are situations where the breast is the site of metastasis from some other primary cancer. When this is the case, the coders will have to apply a code for malignant neoplasm of the breast and for the other cancer that is primary. It is necessary to know the primary site of metastasis as the treatment and payment methodologies vary for primary and secondary malignancies.
Suggested Documentation for Metastatic Breast Cancer
The clinician is expected to make it known where the primary cancer is, where the metastases are, and whether the primary cancer is still active. It should be clear from the documentation, which site is the focus of treatment at each encounter. Lack of clear documentation, or vague documentation, will result in incorrect coding, denial of claims, and questions from the payer.
Personal History of Breast Cancer
After successful treatment of breast cancer where there is no active disease, ICD-10 instructs coders to use a personal history code instead of an active malignancy code.
Z85.3 – Personal History of Malignant Neoplasm of Breast
The personal history code is only applicable when the malignancy has been cleared and the individual has stopped any active treatment, i.e. chemotherapy, radiotherapy, immunotherapy and/or hormonal therapy. This code signifies the patient had breast cancer, but is not a current case.
Follow-Up and Surveillance Coding
Individuals who finish treatment will often require periodic surveillance appointments as part of their care. In the case where a patient comes specifically for a follow up to breast cancer treatment, the follow up code is to be placed in first position, and the personal history code in second position. This order of codes indicates an encounter that is predominantly for surveillance rather than for active treatment.
Active Treatment vs. History
A common coding mistake happens when active treatment is occurring but coders assign a personal history code. While malignancy treatment is active, the appropriate C50 code must continue to be reported. Classifying active cancer as history can result in compliance issues and loss of revenue.
Important Considerations for Reimbursement
ICD-10 coding is the basis for reimbursement, risk adjustment, and compliance.
Medical Necessity
Diagnosis codes defend the cause of the oncologist’s services (imaging, biopsy, chemotherapy, surgery, and radiation). Too little specificity or inappropriate coding can cause payment to be delayed or denied.
Risk Adjustment and HCC Impacts
Active malignancy codes often fall into high risk adjustment tiers for value-based care. Personal history codes replace cancer codes too soon, which lowers risk scores and consequently reimbursement.
Claim Denials
Examples of claims that will be denied include, failure to document laterality, too many non-specific site codes, mis-sequencing of metastatic disease, and mis-assignment of personal history codes. Coder-provider collaboration and regular audits can reduce these risks.
Unique Breast Cancer Coding Situations
In the case of bilateral breast cancer, one code must be assigned for each breast, because ICD-10 does not allow for a singular code for bilateral malignant breast neoplasms. Recurrent breast cancer must be coded as an active malignancy and therefore should be assigned one of the C50 codes, not as a personal history condition. As for prophylactic mastectomy cases, when there is a genetic predisposition to breast cancer (without active malignancy), there is no C50 code assigned. Rather, genetic susceptibility codes are assigned if they are documented.
Coding Accuracy
Coding breast cancer is a process that takes patience and education, and the guidelines surrounding coding must be communicated effectively to and between the coder and the provider. Compliant billing practices are achieved by reviewing the pathology report, confirming treatment status, using as few unspecified codes as possible, and being familiar with the ICD-10 changes that occur every year. Internal audits are a great way to spot trends and improve documentation to aid the overall efficiency of the revenue cycle, as well as its overall success.
Final Thoughts
The ICD-10 coding for breast cancer for each code must have clear and precise documentation, especially in regard to distinguishing primary active malignancy, secondary metastatic disease, and personal history of breast cancer. Appropriate use of code selection, sequencing, laterality reporting, and documenting clinical data will ensure compliance and reimbursement. Healthcare organizations improve claim coding accuracy and denials justification and foster high-quality oncology care by adherence to code guidelines and the continued collaboration with coding staff.
Make An Appintment With A2ZFAQs
Primary breast cancer is categorized under C50 in ICD-10-CM. Each code is then mapped to a specific breast quadrant and requires laterality (right or left) to be indicated. Careful documentation of the quadrants is necessary for code specificity.
A secondary code is warranted for breast cancer that has spread to any other organ or when there is a primary cancer elsewhere that has spread to the breast. If the primary malignancy is still active, then codes for both the primary and secondary sites need to be reported.
Z85.3 is not appropriate to use if a patient is currently undergoing chemotherapy, radiation, or any other cancer-directed treatment. Even when a patient is in the observation phase of the treatment where there is no evidence of disease, the code should not be used for active disease.
If the follow-up visit is for post-treatment surveillance, the primary code that should be used for the visit is a follow-up code and Z85.3 should be added to indicate the patient’s history of breast cancer.
Common errors include missing laterality codes, coding unspecified sites at metastasized locations, coding metastasis in the wrong order, and coding personal history of breast cancer in the active treatment. These errors can be avoided by thorough review of the documentation.