Diagnostic documentation for oncology

Part 1 of 2

Specific documentation is needed to reflect the severity of illness of these patients, as well as their associated risks, complexity of care, resources, and costs of care.

The many conditions that complicate the care of oncology patients receive special attention and consideration in the ICD-9/ICD-10 classifications and the official coding guidelines. Diagnostic documentation needs to be particularly specific to properly reflect the severity of illness of these patients, as well as their associated risks, complexity of care, resources, and costs of care. We will identify and discuss the documentation nuances for oncology patients in this and next month's column.

Primary versus secondary sites

Photo by Thinkstock
Photo by Thinkstock.

Coding classifications greatly emphasize the distinction between the primary site of malignancy and any secondary (metastatic) sites. Thus, it is important for a coder to know if the primary site has been removed or eradicated and whether that site is currently being treated. For example, radiation treatment or chemotherapy for localized breast cancer following mastectomy constitutes treatment of the primary site, even though the malignancy has been removed. When the primary site has not been eradicated, it should be made clear in the record whether the admission is for specific treatment/evaluation of the primary site, any secondary (metastatic) sites, or both.

Oncology patients may present with many signs and symptoms, the causes of which may be unclear. As a patient's evaluation progresses, the confirmed or suspected cause(s) should be clarified and any relationship to primary or secondary sites should be specifically identified. If the cause or causes remain uncertain, physicians should be aware of the legitimate documentation practice, endorsed by the official coding guidelines. This is to qualify any uncertain or unconfirmed diagnosis, if clinically reasonable with appropriate treatment or other management reflected in the medical record, as: probable, possible, suspected, most likely, consistent with, compatible with, indicative of, suggestive of, comparable with, or appears to be. When such qualifying terminology is used, it ought to be included in the discharge diagnoses to demonstrate that circumstances did not change prior to discharge.

Some patients are admitted with widespread, progressive, usually end-stage malignancy. The specific reasons for admission may be obscure, and management is often supportive in nature. In such situations, the diagnosis of “carcinomatosis” may clarify and explain these circumstances to assist with correct coding.

Reasons for admission

Patients with cancer often present with many conditions that make admission necessary, and coders must be able to discern the relative contribution of these conditions to the admission decision. Clarify any treatment or evaluation directed toward primary or secondary sites of malignancy, since this will often be considered the principal diagnosis for coding purposes. Any need for reevaluation of the extent or progression of malignancy, or new organ-system involvement, also should be identified.

Make it clear when a patient is admitted only for chemotherapy or radiation therapy, since these have unique admission codes and the malignancy is not considered the principal diagnosis. Clarification is also needed when an oncology patient requires admission solely for control of severe intractable pain and no other treatment or evaluation is conducted.

Coding rules indicate that admissions for certain complications of cancer care—including dehydration, electrolyte imbalance and anemia—should be designated as the reason for admission when there is no treatment or evaluation of the malignancy and no other particular reason for admission. Clinicians should clearly indicate whether additional evaluation for the cause of these complications was necessary or if other conditions were also evaluated or treated.

Some oncology patients may be admitted for severe anemia requiring blood transfusion. It helps coders to know if anemia is due to the malignancy and/or chemotherapy or to another cause, such as acute or chronic gastrointestinal bleeding. On occasion, platelets are also transfused for coexisting thrombocytopenia, in which case the specific documentation of thrombocytopenia as a cause of admission in addition to anemia is important.

Brain involvement

Two common, potentially life-threatening complications of primary and metastatic tumors involving the brain are cerebral edema and brain compression. Both are easily recognized on imaging studies. Unfortunately, coders cannot use documentation from radiology reports; the clinician must “interpret” the clinical significance of these findings with a precise diagnostic statement in his or her notes.

Cerebral edema represents intracerebral edema in response to the neoplasm. There may be only a thin rim of edema around a tumor with no particular clinical implications or treatment needs. This situation should be distinguished from more widespread edema, typically with narrowing of the ventricular space or an ominous midline shift of the falx cerebri. The former condition would not be separately coded, but the latter would be classified as a most serious complication of the malignancy. However, simple descriptions of “midline shift” and “ventricular narrowing” cannot be coded, so a specific diagnosis of cerebral edema must be documented together with evidence of treatment, further evaluation and/or monitoring of neurologic status. If only a rim of edema is present, clarify whether it has management implications or is simply a routine finding commonly associated with brain tumors.

Brain compression represents external compression by a tumor and, as with cerebral edema, may or may not have clinical management implications. Specific documentation of such cerebral compression is necessary and must include whether further treatment, evaluation or observation of neurologic status is needed.

Seizures commonly occur in patients with brain tumors and may be treated prophylactically. When patients are admitted following a seizure, it is very important to ultimately clarify whether the seizure was considered tumor-related or not.


In summary, always clarify whether the primary or secondary (metastatic) sites of a malignancy, or both, are the cause of symptoms and/or the focus of admission. Has the primary site been eradicated? Is chemotherapy or radiation therapy still being administered for treatment of the primary malignancy? Does the admission involve evaluation, management, or treatment of the malignancy or reassessment of its extent or new organ-system involvement? Is the primary reason for admission simply a complication of the malignancy (such as anemia or dehydration)? Is chemotherapy or radiation therapy the only reason for admission? When there is brain involvement, identify and document the clinical significance of cerebral edema, brain compression and tumor-related seizures.

In next month's column, we will investigate the clinical, coding and documentation nuances of 2 common and serious conditions associated with malignancy and its treatment: pancytopenia and the sepsis/systemic inflammatory response syndrome (SIRS) conundrum.