Review Neoplasm Coding Before Exam
Patricia Maccariella, RRA, CCS
The coding of neoplasms can be very tricky at times. There are many references to neoplasm coding contained within the Coding Clinic. In addition, some of the CPT code assignments are based upon whether the patient has a benign or malignant lesion. Do not forget to thoroughly review the neoplasm table in the ICD-9-CM index.
The guidelines for neoplasm coding are contained in section 2.13, A-H of The Official ICD-9-CM Guidelines for Coding and Reporting. We will review these specific guidelines, and then take a short quiz to test your knowledge!
A. If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis, except when the purpose of the encounter or admission is for radiotherapy session(s), V58.0 or for chemotherapy session(s), V58.1, in which instance the malignancy is coded and sequenced second. Careful review of documentation is necessary to ascertain the reason for admission in malignancy cases. Make a note to review documentation any time that you see chemotherapy or radiotherapy was administered. Do not forget to code the chemotherapy procedure, 99.25 or radiotherapy procedure, 92.21-92.29.
B. When a patient is admitted for radiotherapy or chemotherapy and develops complications such as nausea, vomiting or dehydration, the principal diagnosis is Encounter for radiotherapy, V58.0 or Encounter for chemotherapy, V58.1. The codes for the complications would be listed as secondary diagnoses.
C. When an episode of inpatient care involves surgical removal of a primary or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal diagnosis, using codes in the 140-198 series or, where appropriate, in the 200-203 series.
D. When the reason for admission is to determine the extent of the malignancy (such as a biopsy), or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal diagnosis, even though the chemotherapy or radiotherapy is administered.
E. When the primary malignancy has been previously excised or eradicated from its site, and there is not adjunct treatment directed to treat the site (such as chemo-therapy), and no evidence of any remaining malignancy at the primary site, use the appropriate code from the V10 series to indicate the former site of the primary malignancy. Any mention of extension, invasion or metastasis to a nearby structure or organ or to a distant site is coded as a secondary malignant neoplasm to that site and may be the principal diagnosis in the absence of the primary site.
F. When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. For example, if a patient has ovarian cancer and is admitted with metastasis to the bone, and the patient receives treatment for the bone metastasis only, list 198.5 as the principal diagnosis and 183.0 as a secondary diagnosis.
G. Symptoms, signs and ill-defined conditions listed in Chapter 16 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm. For example, a patient brought into the hospital for treatment of vesical pain attributed to carcinoma of the bladder would be assigned a code from the 188.X series. Code 788.9 (vesical pain) would not be assigned. Remember that this guideline applies to codes in Chapter 16 of the ICD-9-CM coding book only.
H. Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines:
1. When admission is for management of an anemia associated with malignancy, and the treatment is only for anemia, the anemia is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy. Be sure that the physician has documented the cause and effect relationship between the anemia and the malignancy.
2. When the admission is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is designated as the principal diagnosis followed by the appropriate code(s) for the malignancy.
3. When the admission is for management of dehydration due to malignancy or therapy, or a combination of both, and only the dehydration is being treated (as with IV hydration), the dehydration is designated as the principal diagnosis, followed by the code(s) for the malignancy.
4. When the admission is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy, designate the complication as the principal diagnosis if treatment is directed at resolving the complication.
The above official guidelines may not cover every situation encountered in neoplasm coding. When this occurs, research the previous general official guidelines and follow any directives contained in them. In addition, Coding Clinic has many references to the coding of neoplasms, and it is a good idea to review each one. See the Coding Clinic index or a study guide for a list of all the relevant issues containing neoplasm entries. You may want to write yourself reminder notes within your codebooks. Remember also that Morphology codes (M codes) will not be assigned on the examinations. Meta-stasis, direct extension and secondary malignancy are all synonymous in ICD-9-CM.
Take this quiz to test your knowledge:
1. A patient was admitted as an inpatient due to vertigo, syncope and transient alteration of awareness. The patient has a history of ovarian cancer and is being treated with chemotherapy. The patient is to have her sixth course of chemotherapy next week, having had the ovaries removed during a previous surgery. The physician orders a CT scan of the brain, which reveals that the patient has metastatic carcinoma to the brain–which caused the symptoms. What diagnosis code should be assigned as the principal diagnosis?
a) 183.0 (ovarian carcinoma)
b) 780.2 (syncope), 780.02 (transient alteration of awareness) or 780.4 (vertigo). It would not matter which of these are first since the patient was admitted with all three of these conditions.
c) 198.3 (metastasis of malignancy to brain)
d) V58.1 (encounter for chemotherapy)
2. The term mesenchyme is associated with what types of tumor cells?
a) meningioma, glioma and mixed cells
b) sarcoma, fibroma and leiomyoma
c) adenoma, papilloma and squamous
3. A patient is admitted with history of malignant neoplasm of the breast. An excision of the neoplasm was performed previously and the lesion completely removed. The patient now presents as an outpatient with a breast mass in the left lower-outer quadrant of the breast. A needle biopsy is performed and confirms that the breast mass is carcinoma. What diagnosis code(s) are assigned, principal first?
a) 174.5 (malignant neoplasm female breast, lower-outer quadrant)
b) 174.8 (malignant neoplasm female breast, contiguous sites)
c) 611.72, (breast mass) and V10.3 (history of breast carcinoma)
d) V10.3 (history of breast carcinoma)
4. A patient presents to the physician’s office for an annual gynecological examination. The patient also complained of a “bump” within the vagina. A 9-cm mass was discovered on the vaginal wall upon examination. An exploration and biopsy is scheduled for the next week. What code is assigned for the diagnosis?
a) V71.1 (observation for suspected malignant neoplasm)
b) 239.5 (neoplasm, unspecified, vagina)
c) 625.8 (other specified symptoms, female genital system)
d) V72.3 (annual gynecological exam)
5. A patient is admitted with pleural effusion. A thoracentesis is done. Cytology reveals that the patient has malignant pleural effusion. The patient also has metastasis to the bone from an unknown primary. Which diagnosis codes are correct for this case, principal being first?
a) 511.9 (pleural effusion), 198.5 (secondary malignancy of bone), and 197.2 (secondary malignancy to pleura)
b) 511.9 (pleural effusion), 199.1 (unknown primary malignancy) and 198.5 (secondary malignancy of bone)
c) 199.1 (unknown primary), 197.2 (secondary malignancy of pleura) and 198.5 (secondary malignancy of bone)
d) 197.2 (secondary malignancy of pleura), 199.1 (unknown primary malignancy) and 198.5 (secondary malignancy of bone)
6. A patient presents to the outpatient clinic for follow up of a jejunum plasmacytoma. An MRI revealed that the malignant neoplasm had grown and it was questionable as to whether the tumor had spread. Further work up is planned at a later date. How is the case coded?
a) 152.1 (malignancy, jejunum)
b) 239.0 (neoplasm, uncertain behavior, jejunum)
c) 203.80 (other immunoproliferative neoplasm)
d) 197.4 (secondary malignant neoplasm, jejunum)
Patricia Maccariella is manager of coding services at United Audit Systems Inc. (UASI), headquartered in Cincinnati.