The Consultant's Query: 'History of' Cancer, Low BMI, and a Leading Question
Dr. Patel documents in a follow-up note: 'History of colon cancer, status post resection 2018, no evidence of disease. Anemia, likely due to chronic disease. BMI 17.8 with 6 kg weight loss over six months. Continue routine surveillance.' He asks the practice's contracted coding consultant to 'make sure we're getting credit for the cancer and the malnutrition.' The consultant drafts a query reading 'Would you agree this patient has active metastatic colon cancer? Yes/No' and adds C18.9 (malignant neoplasm of colon, unspecified), E43 (unspecified severe protein-calorie malnutrition), and R64 (cachexia) to the submission file for the visit. The practice is preparing for a payer chart audit and the compliance officer has asked you to review the file before it is transmitted.
1. Evaluate each of the three proposed codes and the query. Which can be submitted as documented?
Read the worked answer
C18.9 - reject. The note says 'history of,' 'status post resection 2018,' and 'no evidence of disease.' That is a personal history, coded as Z85.038 (personal history of other malignant neoplasm of large intestine), which carries no HCC. Submitting C18.9 converts a documented remission into an active malignancy - a fabrication finding, not a specificity issue.
E43 - reject as undocumented. BMI 17.8 and 6 kg of weight loss are clinical indicators, not a provider diagnosis of malnutrition. Neither a lab value nor a BMI can be coded as malnutrition; the provider must state the diagnosis and, ideally, the type and severity. This is a legitimate query target, not a legitimate code.
R64 - reject. Cachexia is a symptom, is not HCC-bearing, and is being inferred from weight loss the provider attributed to nothing. Coding it adds risk with no payment upside.
The query - reject and rewrite. 'Would you agree this patient has active metastatic colon cancer?' is a textbook leading query: it supplies both 'active' and 'metastatic,' neither of which appears in the record, and it offers only a yes/no path to an HCC. It would be flagged in any query audit.
Anemia is codable as anemia only (D64.9) if the provider documented it as a diagnosis; 'likely due to chronic disease' is uncertain, so D63.8 with a linked chronic disease is not supported without clarification.
2. Rewrite the query compliantly and describe how you would handle the physician's request for 'credit.'
Read the worked answer
Rewrite:
'The note of [date] states: "History of colon cancer, status post resection 2018, no evidence of disease. Anemia, likely due to chronic disease. BMI 17.8, 6 kg weight loss over 6 months."
- Is the colon cancer currently active, in remission, or a personal history only? (If active, please document the site and any metastatic involvement.)
- Does the patient meet criteria for malnutrition, and if so, what type and severity?
- Is the anemia related to a specific chronic condition, or is the etiology undetermined? Provider response: ______ / Unable to determine: ______'
This version quotes the record, offers a neutral range of answers, asks about the cancer without suggesting a stage, and gives an explicit 'unable to determine' option.
Handling the 'get credit' request: explain in writing that risk adjustment credit follows documentation, not the reverse. State plainly that C18.9, E43, and R64 will not be transmitted, cite the specific language in the note, and note that submitting them would create repayment exposure plus potential False Claims Act risk if done knowingly. Log the request, the review, and the outcome in the compliance file. If Dr. Patel believes the patient is malnourished, the remedy is a documented diagnosis - which is also better care - not a code placed ahead of the note. Escalate if the request is repeated after the explanation.