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Provider Manual

Risk Adjustment - Cancer

Last Updated on January 24, 2019

Hierarchical Condition Category Coding and Cancer

Almost all diagnosed   active   cancers are associated with a hierarchical condition category code (HCC).  However,   “history of”  cancer is not associated with a HCC.  Thus, it is important that cancer is documented and coded accurately, following ICD-10 coding guidelines. 

When diagnosing cancer, it is important to include the following in documentation about cancer:

  • Location – Anatomic part of the body
    • Overlapping site boundaries
    • Multiple non-contiguous sites in same location
  • Type of lesion – histology or cell type if known
  • 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.
  • Treatment – What is being done to eradicate the cancer, is it targeting the primary or secondary malignancy, any associated complications
    • Chemotherapy
    • Radiation therapy
    • Immunotherapy
    • Surgical intervention
    • Brachytherapy
    • Patient declines or is unable to have treatment

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.

Questions

Brenda Anderson
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9598

Ann Meverden
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9352

Shared email:   rf.shp.risk.adjustmnt@securityhealth.org