When coding for cancer diagnosis, here is a handy on line dictionary on cancer terms from National Cancer Institute.
https://www.cancer.gov/publications/dictionaries/cancer-terms
Cancer Types tab
Select a type of cancer to learn about treatment, causes and prevention, screening, and the latest research.
NCI Dictionary of Cancer Terms
The NCI Dictionary of Cancer Terms features 8,727 terms related to cancer and medicine.
cancer type
https://www.cancer.gov/publications/dictionaries/cancer-terms
Chart documentation may include location, site, laterality, specific site on body, including stage (how much has grown and spread).
Document current status of neoplasm, if responding to treatment, or if historical with no active treatment or recurrence
Consider using the term 'in remission' in place of 'history of' when describing the cancer, as appropriate.
When adjuvant therapy is used, document its purpose if curative, palliative or preventive.
Document an referrals or consults and when patient is to return. This is not an all inclusive list as each type of cancer will have its unique documentation.
Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.
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