Compliance Fiasco Coming in Tamoxifen Coding?

[Laureen]

Here is an excerpt from an article written by a colleague of mine that I greatly admire.

By Sheri Poe Bernard, CPC, COC, CCS-P

I see a compliance fiasco waiting to happen in risk adjustment regarding tamoxifen and breast cancer coding.

I was a minority of one regarding active breast cancer vs. history of breast cancer coding at a discussion during a recent HEALTHCON session, but I feel confident that I am the one doing it correctly.

The consensus of RA coders attending the presentation was that a patient who has completed treatment for breast cancer, but is still taking tamoxifen can confidently be coded as having breast cancer. I disagree.

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[Deb McEachern CPC]

Here is an excerpt from an article written by a colleague of mine that I greatly admire.


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I disagree with Sheri's opinion. Oncology nurses agree that tamoxifen is a treatment for breast cancer. And as long as cancer is being treated then it can be a captured HCC. This is similar to men taking lupron for prostate cancer.

 

[Alicia Scott]

The point I get from this article is that we need to consider more then just seeing tamoxifen in the encounter and coding it. Don't you feel this is going to fall back to documentation?

What an exciting debate this is. The reason I love a good, traditional debate is that you learn so much from both sides. Ultimately we are going to have to have some specific guidelines regarding this I suspect.

I look forward to more conversation regarding this topic.

 

[Doug Palmer]

The issue I have here is...opinions are great and make for interesting conversation. However, we as Coders are not empowered to make medical judgements. If a treatment is a treatment and it is documented, outside of pursuing some ethical breach or concern, we must accept the documentation of medical providers as valid. Unless there is a guideline that directs us, the documentation is the documentation and the medical treatment rendered is the medical treatment rendered. We can question that through query, but we cannot take it upon ourselves to make medical judgment. It is very dangerous and slippery slope when we step outside our scope of practice and begin to independently make medical judgements. The Guidelines for Risk Adjustment are MEAT or TAMPER. That is the standard that we are authorized to apply. Until and unless there is a guideline that allows us to decide when treatment is or is not warranted, then this is what we are guided by.

 

[Holly Cassano]

This is an excerpt from one of the biggest MA plans in the country and they are a 5 Star Plan - which means they pass CMS compliance guidelines pretty much - spot on...............I can't publish the name here as it is proprietary from an audit I worked on for them.

For any diagnosis of cancer Coders must use the entire DOS to determine whether the malignancy should be coded as a “history of” or “current”.
Current cancer must have supporting documentation to indicate the cancer is either one of the following….

Still physically present in the body

Still being actively treated (chemo, radiation/brachytherapy/seeds)—even if the cancer has been surgically resected/removed

Requires long-term maintenance medication/suppressive therapy (e.g., Lupron, Tamoxifen, etc. for breast or prostate cancer)

Requires surgical treatment (e.g. a preoperative examination prior to colectomy)

Not being treated at either the patient’s, family’s or physician’s discretion (e.g. choosing not to continue treatment of a terminal disease)