Former primary site and active metastasis

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-08-24 · Outpatient professional service

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Reason for visit

An outpatient oncology encounter is devoted to management of an active secondary malignant neoplasm of the liver. No chemotherapy, immunotherapy or radiation administration occurs during this encounter.

Cancer history

The clinician documents that the former colon primary was eradicated. No primary malignancy remains at that site, and no further treatment is directed to the former primary site.

Current assessment

The liver metastasis remains active and is the condition managed today. The record does not describe a new primary liver malignancy.

Task boundary

Determine active-versus-history status and the site receiving care. Do not convert the active secondary site to history or invent a new primary site.

Your coding worksheet

Identify which site has active malignancy.
Check whether the former primary meets the history conditions.
Find the guidance for treatment directed only to a secondary site.
Verify the relevant active-secondary and former-primary-history candidates.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The liver site is an active secondary malignancy according to the provider.
The former primary meets all stated history conditions: eradicated, no remaining primary malignancy and no further treatment directed there.
The secondary site is the focus of management; the former primary does not automatically take priority.
Keep the active metastasis distinct from history of the former primary. This is not a therapy-administration encounter.

Reference sections: I.C.2.b,d

Practice the linked chart questions