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Specificity key to neoplasm coding in ICD-10-CM

JustCoding News: Inpatient, August 29, 2012

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by Betty Hovey, BA, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC

Neoplasm coding in ICD-10-CM is similar to the current ICD-9-CM coding. Most benign and all malignant neoplasm codes are found in chapter 2 of ICD-10-CM, just as in ICD-9-CM. The ICD-10-CM manual includes many guidelines regarding the proper way to code them.
 
For coders to properly code a neoplasm, the medical record must include documentation as to whether the neoplasm is:
  • Benign
  • Malignant
  • In situ
  • Uncertain behavior
The Alphabetic Index contains a Neoplasm Table that corresponds to this terminology, just as it does currently in ICD-9-CM.
 
The chapter two guidelines also state that if a histological term is documented, that term should be referenced first, instead of going directly to the Neoplasm Table to determine which column in the Neoplasm Table is appropriate.
 
For example, if the documentation states “adenoma”, the user would look up that term first. The Alphabetic Index lists many terms and codes, such as adrenal (D35.00), chief cell (D35.1), and rete cell (D29.20).
 
It also indicates that the Neoplasm Table is appropriate for other types of adenomas with the indication to “see Neoplasm, benign, by site” at the beginning of the listing and with other terms, such as polypoid (see also Neoplasm, benign) and prostate (see Neoplasm, benign, prostate).
 The Neoplasm Table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. Coders should then reference the Tabular List to verify that the correct code has been selected from the table and that a more specific site code does not exist.
 
According to the 2012 ICD-10-CM Official Guidelines for Coding and Reporting (C.2) for a primary malignant neoplasm with two or more contiguous overlapping sites, coders should classify the sites to the subcategory/code with .8 (overlapping sites), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, coders should assign codes for each site.
 
Coding examples of contiguous sites
 
A patient presents with a primary malignant tumor in the splenic flexure and transverse colon. When coders look up Tumor, malignant in the Alphabetic Index, it directs the user to “see Neoplasm, malignant, by site” (the Neoplasm Table). When coders look up Intestine ,splenic flexure, malignant, primary, and Intestine, transverse, malignant, primary in the Neoplasm Table, it directs the user to C18.5 and C18.4.
 
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
 
In our example, the patient has a malignancy that has invaded the splenic flexure and transverse colon, which are contiguous sites. Instead of coding both C18.5 and C18.4, the user would code C18.8, Malignant neoplasm of overlapping site of colon. This is also a good example of the anatomy knowledge that a coder will need to possess to understand how to apply the guidelines correctly.
 
Consider also the follow example: A female patient presents with two malignant neoplasms of the left breast; one in the upper-outer quadrant and one in the lower-inner quadrant. When coders look up Breast in the Neoplasm Table, specific sites are listed. When coders look up Breast, lower-inner quadrant, malignant, primary, it directs them to C50.3-. When coders look up Breast, upper-outer quadrant, it directs them to C50.4-.
 
When coders look up code C50.3 in the Tabular Index, they will find that additional characters are necessary to indicate the gender of the patient and laterality. This includes:
 
C50.311          Malignant neoplasm of lower-inner quadrant of right female breast
C50.312          Malignant neoplasm of lower-inner quadrant of left female breast
C50.319          Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.321          Malignant neoplasm of lower-inner quadrant of right male breast
C50.322          Malignant neoplasm of lower-inner quadrant of left male breast
C50.329          Malignant neoplasm of lower-inner quadrant of unspecified male breast
 
When coders look up code C50.4 in the Tabular Index, they will find that additional characters are necessary to indicate the gender of the patient and laterality, as follows:
 
C50.411          Malignant neoplasm of upper-outer quadrant of right female breast
C50.412          Malignant neoplasm of upper-outer quadrant of left female breast
C50.419          Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.421          Malignant neoplasm of upper-outer quadrant of right male breast
C50.422          Malignant neoplasm of upper-outer quadrant of left male breast
C50.429          Malignant neoplasm of upper-outer quadrant of unspecified male breast
 
In our example, the female patient has two malignancies of the left breast that are not contiguous. The two codes that would correspond to our example are C50.312, Malignant neoplasm of lower-inner quadrant of left female breast, and C50.412, Malignant neoplasm of upper-outer quadrant of the left female breast.
 
Coding example of neoplasm sequencing
 
The guidelines also provide information regarding sequencing of neoplasms. The 2012 ICD-10-CM Official Guidelines for Coding and Reporting (C.2.a) states if the treatment is directed at the malignancy, coders should assign the malignancy as the principal/first-listed diagnosis. The only exception is when the patient presents solely for administration of chemotherapy, immunotherapy, or radiation therapy. Then, coders should assign the proper Z51 category code as the principal/first-listed diagnosis, with the malignancy as a secondary diagnosis while the service is being performed.
 
EXAMPLE: A patient, after having a lobectomy, now returns for radiation therapy today. Since the patient presented for treatment the codes would be, in order:
 
Z51.0   Encounter for antineoplastic radiation therapy
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
 
According to the 2012 ICD-10-CM Official Guidelines for Coding and Reporting (C.2.b) (C.2.l.1) if the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. Coders should sequence first the primary site, followed by any metastatic sites. When a patient is admitted because of a primary neoplasm with metastasis (secondary spreading) and treatment is directed toward the secondary site only, the secondary neoplasm is the principal diagnosis even though the primary malignancy is still present. What this means is that the primary site is not always the first-listed code, nor is the metastatic site always the second listed code.
 
EXAMPLE: A patient has a primary malignancy in the right renal pelvis that metastasizes to the right ureter and presents for treatment of the ureter. Since the patient presented for treatment of the secondary site only, coders would report codes in the following order:
C79.19            Secondary malignant neoplasm of other urinary organs        
C65.1 Malignant neoplasm of right renal pelvis
 
The 2012 ICD-10-CM Official Guidelines for Coding and Reporting also address coding and sequencing of malignancies, of complications associated with the malignancies, or with the therapy therof are subject to specific guidelines. For example, if there is an encounter for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the first-listed diagnosis followed by the appropriate code for the anemia. This is different than how we currently code it in ICD-9-CM.
 
EXAMPLE: A patient is admitted to the hospital for treatment of malignancy-associated anemia. The patient has malignant neoplasm of the fundus of the stomach. The only treatment given is for the anemia. In this scenario, although the patient is being treated only for the anemia, coders must report the malignancy first.
 
C16.1 Malignant neoplasm of fundus of stomach
D63.0 Anemia in neoplastic disease
D63.0 has an instructional note underneath it that states to code first neoplasm (C00-D49). This follows the guideline listed above and indicates that order of the codes.
 
Neoplasms can be coded many different ways in ICD-10-CM. The guidelines are listed to ensure proper coding and sequencing. Specific, straightforward instructions give the user direction in the approved way to assign chapter 2 codes. Refer to the official guidelines in the ICD-10-CM Manual for the complete guidelines for this and all chapters.
 
Betty A. Hovey, BA, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC, is the director of ICD-10 development and training for the AAPC. She has 25 years experience in physician coding, billing and education in many different types of health care settings. She has worked with teaching facilities, emergency departments, and practices small and large. Hovey has worked with multiple different specialties, including Cardiology (Diagnostic, Cardiothoracic, and Cardiovascular), Dermatology, Plastic Surgery, and Family Medicine. Betty currently focuses on ICD-10 training and curriculum development. Prior to coming to the AAPC, Hovey ran a private consulting company and spoke nationally for many groups, including coding organizations and health plans. She served on the National Advisory Board of AAPC from 2004–2007, and was elected as an officer on the Board from 2005–2007. She is currently an AAPC ICD-10 Expert Trainer and presents boot camps and onsite training in ICD-10 nationally.



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