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National Breast Cancer Awareness Month (Oct 2026): Documentation and Coding Resources for Your Practice
Act
immediately
Effective date
Not stated in the notice
Identified
Oct 2, 2026
Summary
Healthfirst has released updated documentation and coding guidance for breast cancer diagnosis and treatment to ensure accurate ICD-10-CM code selection. The policy clarifies how to code malignant neoplasms, metastatic disease, adjuvant therapy (curative vs. prophylactic), and follow-up care, with critical distinctions between active treatment and post-treatment status that directly impact claim coding accuracy.
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What to do
immediately · 5 steps
01Providers and coding staff must review the breast cancer coding guidance on HFproviders.org/Coding.
02Update documentation templates and encounter forms to capture required clinical details: (1) specific form of breast cancer (primary, in-situ, or metastatic); (2) anatomic site, quadrant, and laterality; (3) risk factors (family history, BRCA status, estrogen receptor status, obesity, menopausal status); (4) adjuvant therapy purpose (curative, palliative, or prophylactic) and S/P treatments; (5) treatment status (active, completed, or no evidence of disease).
03Train coding staff on the Case 1 vs. Case 2 distinction: if adjuvant therapy purpose is not documented or cancer-free status is not stated, code as current/active malignancy (Case 1); if documentation explicitly states prophylactic purpose or NED, code as history (Case 2).
04Clarify with providers any ambiguous documentation before submitting claims.
05Contact the Risk Adjustments and Clinical Documentation team (#Risk_Adjustments_and_clinical_Documentation@healthfirst.org) for questions.
If missed: Failure to accurately code per this guidance may result in claim denials or compliance issues with Healthfirst.
Codes mentioned
C50C50.AC77.3Z12.31Z12.39Z80.3Z85.3Z86.000Z08
Original notice
National Breast Cancer Awareness Month (Oct 2026): Documentation and Coding Resources for Your Practice
hfproviders.org · Always check the source before changing claims.