ICD-10 documentation guidance for cancer
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Guidance for clinical documentation of neoplasms to support accurate ICD-10-CM coding, intended for clinicians and coding professionals working with Independence Blue Cross records.
No material clinical or coverage changes in this revision.
Active disease vs History — Coding Criteria
Active disease vs history coding
Criteria to distinguish active malignant neoplasm from history of malignancy for coding purposes:
ALL of the following
- The patient is not receiving active treatment
- There are no indications of current disease
- Then assign a code from category Z85 (Personal history of malignant neoplasm).
Otherwise
- If the patient is receiving continuing treatment (example: Tamoxifen)
- Or there is documentation or indication of current disease or recurrence
- Then document as active malignant neoplasm and assign the appropriate C‑code (example: C50.- for breast cancer; additional characters required).
Do not use a Z85 history code when active treatment is ongoing; document as active cancer instead.
ICD-10 Coding Examples
| Z85 | Personal history of malignant neoplasm (use when no active treatment and no current disease) |
| C50.- | Breast cancer (example of active cancer code; additional characters required) |
Documentation & Actionable Guidance for Clinicians
General documentation requirements
Document to the highest specificity and severity, including laterality when relevant. Clearly differentiate whether the neoplasm is benign, in‑situ, malignant, or of uncertain histologic behavior.
- Include laterality when applicable.
- Differentiate benign vs in‑situ vs malignant vs uncertain histologic behavior.
Malignant neoplasm documentation
For malignant neoplasm, document the primary site and any secondary sites, and include details of current treatments such as chemotherapy, radiation, hormonal therapy, surgery, watchful waiting, or refusal of treatment.
- Primary site (original site of the cancer).
- Secondary sites (locations where cancer has spread).
- Current treatments: chemotherapy, radiation, hormonal therapy, surgery, watchful waiting, or refusal of treatment.
Active vs history coding guidance
If the neoplasm has been excised or eradicated and the patient is not receiving active treatment and there are no indications of current disease, assign a Z85 (personal history of malignant neoplasm) code; if the patient is receiving ongoing treatment or there is evidence of current disease, document as active malignant neoplasm and use the appropriate C‑codes.
- Use Z85 when the neoplasm is excised/eradicated, no active treatment is being given, and there are no indications of current disease.
- If the patient is receiving treatment (example: Tamoxifen) or there is indication of current disease, document as active cancer and report appropriate C‑codes (e.g., C50.- for breast cancer, with required additional characters).
Neoplasm Type Definitions
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