Clinic documentation states: “Follow-up for post-induction chemotherapy for metastatic uterine cancer.

When documentation states “metastatic uterine cancer,” the most important missing element for complete, accurate outpatient coding iswhere the cancer has metastasized(the secondary site[s]). In ambulatory CDI, identifying secondary sites best clarifies the full scope of disease being monitored and treated because metastatic disease coding relies on documenting both the primary malignancy and the specific metastatic location(s) (e.g., lung, liver, bone, peritoneum, lymph nodes). This supports correct severity representation, risk capture, treatment intent, and medical necessity for ongoing chemotherapy follow-up. While tumor morphology can be clinically relevant, it is usually established earlier in the diagnostic pathway and does not, by itself, define current metastatic burden. Likewise, reviewing labs or MRI results may provide supportive indicators, but they do not replace provider documentation of theconfirmed metastatic sitesbeing managed. A compliant query focused on secondary sites prompts the provider to document the current metastatic disease status (active, responding, progressing) and specific locations, which most directly identifies the conditions under treatment.