Tuesday, July 24, 2012

Coding Neoplasms

Neoplasms - The first step in choosing the correct code.


The word "neoplasm" is often used interchangeably with the word "cancer" despite this inaccuracy. Neoplasm, which literally means "new growth," is an abnormal mass of tissue, and can be benign (not cancer) or malignant (cancer).


Understanding the differences in primary, secondary, in-situ, benign and undetermined behavior neoplasms is the first step in choosing the correct neoplasm code. A primary neoplasm is cancer (malignant), and designates the location (its origin) of where the cancer started. A secondary neoplasm (metastases) is cancer (malignant) that designates where the cancer spread. In-situ is cancer (malignant); however, it is confined to a specific area of origin, such as in the cervix or breast. A benign neoplasm is not cancer and is a localized tumor that has well-differentiated cells that do not metastasize or invade surrounding tissues. Some examples of benign neoplasms include lipoma, adeoma and hemangioma. A neoplasm of undetermined behavior is a diagnosis that can only be utilized if the pathologist notes in his pathology report that the behavior of the tumor is undetermined.


The general guidelines for neoplasms include first determining if a neoplasm is benign, in-situ, malignant or of uncertain histological behavior. In addition, if the neoplasm is malignant, determination needs to be made if there are any secondary (metastatic) sites involved. 


The guidelines for neoplasm are divided into nine separate categories to help with assigning the appropriate neoplasm code(s).


1. Treatment directed at the malignancy


If the treatment is directed at the malignancy, assign the malignancy code as the principal diagnosis. (An exception to this rule is when the patient is admitted for chemotherapy, radiation therapy or immunotherapy for the malignancy. In this situation, utilize the V58.x code as the principal diagnosis followed by the code for the malignancy.) An example of this would be a patient with sigmoid colon cancer admitted for a colectomy. The principal diagnosis would be the sigmoid colon cancer (primary site), as opposed to the patient being admitted for chemotherapy for the sigmoid colon cancer. In this situation, the chemotherapy code would be used as the principal diagnosis (V58.11), with an additional code for the sigmoid colon cancer.


2. Treatment directed at the secondary site 


If a patient is admitted with metastatic cancer, and the treatment is directed toward the secondary (metastatic) site, utilize the metastatic cancer code as the principal diagnosis followed by the primary cancer site (if still present) or a V code for a history of the primary neoplasm. An example of this would be a patient with prostate cancer who is currently undergoing chemotherapy admitted for a severe headache. After an MRI of the brain, it is determined that the patient has metastatic cancer of the brain from his prostate cancer. The principal diagnosis would be the metastatic (secondary) brain cancer and an additional code would be added for the prostate cancer.


3. Coding and sequencing of complications 


Anemia is often a result of neoplasms, as well as, therapy directed toward the neoplasm. When a patient is admitted for anemia due to a neoplasm and the treatment is directed toward the anemia, utilize the code 285.22, Anemia due to neoplasm as the principal diagnosis followed by the code for the neoplasm. Anemia due to a neoplasm, 285.22, can also be utilized as a secondary diagnosis if the patient suffers from anemia and is being treated for the malignancy.


When a patient is admitted for anemia due to chemotherapy, immunotherapy or radiation therapy, and the treatment is directed at the anemia, the anemia code should be the principal diagnosis. An additional code should be used to capture the neoplasm.


When anemia due to a neoplasm (285.22) and anemia due to chemotherapy (285.3) are both documented on the same encounter, both 285.22 and 285.3 can be coded. If both are documented as the reason for admission, based upon coding guidelines, either can be chosen as the principal diagnosis.


When a patient is admitted due to dehydration due to a malignancy or therapy directed at the malignancy, and only the dehydration is being treated, the dehydration is sequenced as the principal diagnosis followed by a code for the malignancy.


When a patient is admitted due to complications that resulted from a surgical procedure, code the complication as the principal or first-diagnosis if the treatment is directed toward the complication.


4. Primary malignancy previously excised


When a primary neoplasm has been excised and no further treatment (i.e., chemotherapy, immunotherapy, radiation therapy) is being directed toward that neoplasm, and there is no evidence of any existing primary neoplasm, utilize a code from V10.x for a personal history of a malignant neoplasm. Should an extension, metastases or invasion to another site be documented, code a secondary malignancy to that site. The secondary malignancy can be utilized as the principal or first-listed diagnosis followed by a V10.x code for the personal history of a malignancy.


5. Admission/encounter involving chemotherapy, immunotherapy and radiation therapy


When a patient is admitted for the administration of chemotherapy, immunotherapy or radiation therapy, the appropriate V58.x code is used as the first-listed or principal diagnosis followed by the code for the neoplasm(s) that is being treated.


When a patient is admitted for chemotherapy, immunotherapy or radiation therapy, and develops complications, such as dehydration or uncontrolled nausea and vomiting, code the appropriate V58.x code as the principal diagnosis followed by codes for the complications.


When a patient is admitted for the surgical removal of a neoplasm and receives chemotherapy, immunotherapy or radiation therapy after the surgery, the appropriate neoplasm code should be listed as the principal diagnosis.


6. Admission/encounter to determine extent of malignancy


When a patient is admitted to determine the extent of a primary or secondary malignancy, the malignancy is coded as the principal diagnosis.  


7. Symptoms, signs and ill-defined conditions listed in Chapter 16 associated with neoplasms


Should any signs, symptoms or ill-defined conditions listed in Chapter 16 be related with a primary or secondary neoplasm, the neoplasm is listed as the principal diagnosis.  


8. Admission/encounter for pain control/management


When a patient is admitted for pain control due to pain related to a neoplasm, utilize the code 338.3 as the principal diagnosis followed by a code for the neoplasm. In addition, 338.3, pain related to neoplasm can be utilized as the principal or a secondary diagnosis dependent on the reason for admission, and is used if the pain is acute or chronic.  


9. Malignant neoplasm associated with transplanted organ


When a patient is admitted for a malignant neoplasm in a transplanted organ, the principal diagnosis will be a complication of a transplant (996.8x) followed by the code 199.2, malignant neoplasm associated with transplanted organ. Also, utilize a code for the specific neoplasm.


To obtain the correct neoplasm code, the coder should carefully read over the documentation, determine the type(s) of neoplasm(s), assess the reason for admission, and then review the coding guidelines.  


This month's column has been prepared by Meredith McCollum, MBA, RHIA, CCS, ICD-10-CM/PCS AHIMA Certified Trainer, a coding educator with Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. Meredith's position is dedicated to providing ICD-9 and ICD-10 education to both internal colleagues, as well as clients based across the United States. She also is an adjunct professor for DeVry University where she not only teaches ICD-9 and ICD-10, but also develops classes for their nationwide Health Information Technology Program. 


Want to test your knowledge?

Quiz 


1. A patient with small cell carcinoma of the right lower lobe of the lung is admitted for a 7-day treatment of chemotherapy. The chemotherapy is administered, and the patient is discharged. How would this case be coded?


2. A 63-year-old male is admitted with a severe headache and backache. The patient has a history of malignant melanoma 6 years prior with no reoccurrence. An MRI is performed of the brain, spinal cord and vertebrae. The scan notes metastatic disease of the brain, spinal cord and the vertebrae. Radiation therapy is administered prior to his discharge. How would this be coded?


3. A 7-year-old female with acute lymphocytic leukemia (ALL) is admitted with severe anemia due to her ALL. The patient is transfused two units of packed red blood cells and discharged. What would the codes be for this encounter?


4. A 55-year-old male is admitted for pain control due to severe pain related to metastatic bone cancer from a primary lung carcinoma. How is this encounter coded?

Answers


1. The chemotherapy code will be listed as the principal diagnosis (V58.11), followed by a code for the neoplasm of the lower lobe of the lung (162.5). In addition, a procedure code for the administration of chemotherapy can be added (99.25).


2. The secondary neoplasm code for the brain and spinal cord (198.3) will be the principal diagnosis with additional diagnoses for secondary neoplasm to the vertebra (198.5), and V10.82 for personal history of melanoma of the skin. A procedure for the radiation therapy can also be added (92.29).


3. The anemia due to a neoplasm is assigned as the principal diagnosis (285.22) with an additional code for ALL (204.00). In addition, the procedure code for the transfusion of the packed cells can be added (99.04).


4. The code for the pain due to a neoplasm (338.3) is used as the principal diagnosis followed by a code for the metastatic bone cancer (198.5) and primary lung cancer (162.9).


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