Documentation of metastatic disease

When documenting a case with metastatic disease remember to document to location of the mets.

Example
“Colon cancer with metastasis to bone” codes higher severity of illness than “colon cancer with mets” without mention of location.

Btw do not document “history of metastatic colon cancer” – this cannot be coded at all. By the rules a condition with “history of” is no longer present and is not requiring current treatment.

General rule of thumb is if a patient is receiving active treatment for a condition then it should never be documented as “history of”.