According to the American Cancer Society, cancer is the number two cause of death in the United States today, causing nearly 23 percent of all deaths. There are many treatment protocols and programs throughout the country to address the incidence of cancer and all of them depend upon one thing: accurate statistics. Those statistics are generated in large part by the coded data from health care institutions nationwide. Never has it been more important to accurately identify not only those cases with malignancies that have been identified positively, but also those cases for which the diagnosis was found to be benign. As a result of accurately identifying these cases, researchers are able to ascertain whether certain patterns exist, such as higher incidence of a particular malignancy in certain geographic areas of the country or in specific age brackets. These findings then can be investigated to determine whether underlying triggers are present and can be eliminated, or their impact lessened. This column will cover various aspects of coding malignancies and will prepare you for any questions on the CCS or CCS-P exams related to them.
The most important aspect of coding neoplasms appropriately is to first ascertain from the medical record whether the specimen in question is malignant, in-situ (which means that the cancer is confined to the immediate area where it began), benign or of uncertain histologic behavior. This requires that a pathology report be present on the record if the diagnosis is being made on the episode of care that is being coded. Whenever a biopsy or excisional procedure is performed for the expressed purpose of determining whether a particular tissue is malignant or not, the record should not be final coded until the pathology information is present. In the majority of cases, the pathology report is clear and the tumor is identified as either malignant or benign. However, ICD-9-CM has included two sections in the Neoplasms chapter for "Neoplasms of Uncertain Behavior" and "Neoplasms of Unspecified Nature," which should be clearly understood and differentiated by coding staff.
"Neoplasms of Uncertain Behavior" are those for which the final behavior cannot be determined at the time of the biopsy or other excisional procedure because the cells may be undergoing malignant transformation but a firm distinction between malignant and benign can't be made. In most cases, follow-up care is provided to help ascertain whether the patient has any malignancy. In some instances, a portion of the specimen will be sent out to another pathology lab for another opinion. Only then is it appropriate to assign an "uncertain behavior" neoplasm code; they should not be assigned merely to get a claim paid more quickly when the initial pathology report has not yet been received. After the final pathology report has been returned from the outside pathology lab, its results should be reviewed and the coding revised.
Codes for "Neoplasms of Unspecified Nature" should rarely be assigned, and almost never for acute-care facility coding. In this case, neither the behavior nor the morphology of the tissue in question is known at the time of the visit. This situation may result if a patient is transferred to another facility before all diagnostic studies are completed or when a working diagnosis is needed for an outpatient visit and very little information is known. The coder should always attempt to recover more information before assigning these codes and should never assign them if actual treatment is being directed toward the neoplasm; more specific information should be available.
Once the behavior of the tissue in question has been determined, the coder should first turn to the Neoplasm Table in ICD-9-CM unless the actual histological term is documented. If so, the term (such as "adenoma") should be located in the alphabetic index and the entries and instructional notes should be reviewed. For example, the instructional note under "adenoma" instructs the coder to see also, neoplasm, by site, benign. The coder then refers to the Neoplasm Table by anatomical site, benign behavior for the appropriate code. The Neoplasm Table is arranged by anatomical site for each row and the type of histological behavior (malignant, benign, uncertain behavior and unspecified) is described across the col-umns. After a code is located in the Neoplasm Table, it should always be verified in the Tabular portion of ICD-9-CM.
It's also very important to determine from the medical record documentation whether a malignancy is considered "primary" or "secondary," meaning that it is a malignancy that has metastasized from another primary location. Metastasis results when the cancer cells migrate from their initial location to another anatomical location through either the blood vessels, lymphatic channels or by direct extension to nearby tissues. Coders must carefully review physician documentation to ensure appropriate secondary or metastatic site coding. For example, a patient with a remote history of breast cancer (status post mastectomy) that currently has hip pain presents for bone biopsy to rule out metastasis. The pathology report is positive, indicating a breast primary and the attending physician documents "metastatic breast CA." The coder should review both the operative and pathology reports and assign a code for a secondary bone malignancy, not a breast malignancy. The breast tissue is no longer present (the patient is status post mastectomy) and the physician is referring to the cell type by documenting the "metastatic breast CA." A secondary V-code should also be assigned for the history of breast CA.
Coders must also determine when to assign a code for the malignancy, and when to assign the V-code for the "personal history of malignancy" code. As a general rule, when treatment is directed toward a malignancy, that malignancy should be coded. It's not quite as clear-cut as it sounds and many coders experience confusion when dealing with these particular records. For instance, a patient is seen in a physician office and has a skin biopsy performed that reveals malignant melanoma. She is scheduled for outpatient surgery the following week for a wide excision to ensure that no margins contain any residual tumor cells. On the outpatient surgery visit, regardless of whether the pathology report indicates positive cells for malignancy or not, the malignant melanoma code is assigned as the first-listed code. The diagnosis has been made and the patient is still being treated for the melanoma. Until the initial phase of treatment has been provided and the patient has fully recovered, the malignancy is coded.
After the patient has recovered and is seen for follow-up treatment (or for other unrelated visits), the V-code for the personal history of malignancy should be assigned. This is especially crucial for patients who are undergoing biopsies of other areas to determine whether another malignancy exists. Also, ICD-9-CM provides a section of codes for family history of certain malignancies. These codes are important because heredity does appear to play an important role in some neoplasms and the presence of these codes adds an important piece of information to the record. In addition, in some cases, the family history code, such as code V16.0 for family history of colon CA, affects medical necessity for some services. Coders should be diligent however, in differentiating between personal history and family history of malignancy codes. For the vast majority of cases, no history code is reported when the patient has had a prior benign neoplasm, with one exception. For a personal history of a benign brain tumor, code V12.41 should be coded. Unlike most benign neoplasms that are not generally a persistent problem once treated, benign neoplasms of the brain often recur and can be difficult to treat. In addition, benign neoplasms of the brain may be life threatening. Refer to Coding Clinic, 4th Quarter 1997, p. 48, for this guideline.
There are several general guidelines related to coding for metastatic neoplasms. When the diagnostic statement indicates "metastatic to," this means that the site mentioned is secondary. If the primary site is still present, a code for it should also be reported. The statement "metastatic from" indicates that the site mentioned is the primary site and the coder should ascertain whether that malignancy still exists. In addition, the coder should determine the site of the metastasis and assign that code as well. If two or more sites are documented as "metastatic," each of the designated sites should be coded as secondary. A code should also be assigned for the primary site if known; if it is unknown, code 199.1 (Malignant Neoplasm, NOS) should be assigned. When the morphology type isn't stated or the only code that can be determined is either 199.1 or 199.0, assign the code as a primary malignant neoplasm, unless the site is one of the following:
Sites classifiable to 195
Malignant neoplasms of these sites are classified as secondary when not otherwise specified, except for neoplasm of the liver. ICD-9-CM provides code 155.2 (Malignant neoplasm of the liver, not specified as primary or secondary), for use in this situation.
There are several specific coding guidelines related to neoplasms in the ICD-9-CM Official Coding Guidelines in section C2. These include the following:
A. If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
B. 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.
C. Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines:
1. When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy.
2. When the admission/encounter is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by the appropriate code(s) for the malignancy.
3. When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
4. When the admission/encounter 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 or first-listed diagnosis if treatment is directed at resolving the complication.
D. When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.
E. Admissions/Encounters involving che-motherapy and radiation therapy:
1. When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by chemotherapy or radiation treatment, the neoplasm code should be assigned as principal or first-listed diagnosis. When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal or first-listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.
2. If a patient admission/encounter is solely for the administration of chemotherapy or radiation therapy code V58.0, Encounter for radiation therapy, or V58.1, Encounter for chemotherapy, should be the first-listed or principal diagnosis. If a patient receives both chemotherapy and radiation therapy both codes should be listed, in either order of sequence.
3. When a patient is admitted for the purpose of radiotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is V58.0, Encounter for radiotherapy, or V58.1, Encounter for chemotherapy.
F. When the reason for admission/en-counter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
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 or first-listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.
Although these guidelines may appear to be somewhat straight-forward, the coder must review the medical record documentation carefully to determine the circumstances of the admission or visit to ensure appropriate coding. Patients with malignancies necessarily have many visits, both inpatient and outpatient, during their course of treatment and the circumstances vary widely from patient to patient, even among patients with the same diagnosis. Response to treatment varies, manifestations or reactions to treatment vary widely and the patient's tumor status (currently undergoing treatment or past treatment in the "history" phase) are all important considerations that must be reviewed for accurate coding.
After reviewing the neoplasm coding guidelines, test yourself with the questions below:
1. A 72-year-old man with a four-year history of cancer of the prostate was admitted through the ED, complaining of severe lower back pain. He has been diagnosed with metastases to the testes and groin lymph nodes and a recent bone scan showed a "hot" spot in the lower lumbar vertebrae. Lumbar X-ray revealed fracture of the L4 vertebrae. On this admission he was placed in Buck's traction for 24 hours in an attempt to relieve his pain, which was unsuccessful. MRI the next day also revealed metastasis to the spinal cord and vertebrae at the L4 fracture site. He was begun on MS Contin to relieve pain and transfer arrangements were made. The appropriate diagnosis codes are:
a. 733.13, 724.2, 198.5, V10.46
b. 733.13, 198.5, 198.3, 198.82, 196.5, V10.46
c. 805.4, 990, 198.5, 198.3, V10.46
d. 805.4, 198.5, 198.3, 198.82, 196.5, V10.46
2. This patient was admitted with squamous cell carcinoma of the posterior pharyngeal wall and metastasis to the cervical lymph nodes. He has refused surgery and has elected to begin radiation therapy daily on a 6 MV linear accelerator. Each field was treated twice a day, with customized shielding blocks. The treated areas covered the primary cancer, the suspected areas of extension and the lymph nodes in the neck. Which of the following diagnosis codes should be reported for this encounter?
c. V58.0, 149.0, 196.0
d. 149.0, 196.0
3. A 55-year-old patient has a lung mass that was discovered on chest X-ray; he presents to the ambulatory surgery center for a diagnostic bronchoscopy. After anesthetic administration, a fiberoptic bronchoscope is introduced into the bronchial tree, after which a needle is advanced through a channel in the scope and tissue is aspirated from the lung mass for pathologic testing under fluoroscopic guidance. The final diagnosis is oat cell carcinoma. Which of the following represents the appropriate diagnosis and procedure codes?
a. 162.9, 31629, 33.27
b. 162.9, 31629, 33.26
c. 162.9, 31625, 33.24
d. 235.7, 31629, 33.27
4. This 47-year-old female patient has a palpable lump in her right breast and also a smaller lesion in the left breast that was identified on mammography. This lesion was also identified by a radiological marker on this visit. She had an excisional biopsy on both sides. The specimen from the right breast was found to have breast malignancy with clear margins, and the smaller lesion on the left breast was found to have fibrocystic disease only. Which of the following diagnosis and procedure code sets is most appropriate?
a. 174.9, 610.1, 19120-RT, 19125-LT, 19290-LT, 85.21, 85.19
b. 611.72, 610.1, 19120-50, 85.21
c. 174.9, 610.1, 19120-50, 19125-50, 19290-50, 85.21, 85.19
d. 174.9, 610.2, 19120, 19125-59, 19290, 85.21 n
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
Answers to CCP Prep!:
1. b. The scenario does not indicate any trauma, so code 805.4 is incorrect. Also, low back pain (724.2) is inherent to a vertebral fracture and would not be reported separately. All of the various metastatic sites would be coded;
2. c. The encounter for radiation therapy, V58.0, should be the first-listed code and both the code for the primary malignancy (149.0) and the lymph node metastasis (196.0) should be reported;
3. a. Because the procedure was a transbronchial aspiration biopsy, codes 31629 and 33.27 must be assigned. The carcinoma was not specified as a neoplasm of uncertain behavior so code 235.7 is incorrect; ICD-9-CM directs the coder to 162.9;
4. a. Separate CPT codes with RT and LT modifiers show that separate different procedures were performed on each breast for this patient. This is why the 50 (bilateral procedure) modifier should not be assigned. An excisional biopsy was performed on the right (19120) and an excisional biopsy via needle localization technique was performed on the left side (19125 & 19290). The final diagnosis of breast malignancy was made, which should be reported as the first-listed diagnosis (174.9), with a secondary code for the fibrocystic disease (610.1). ICD-9-CM procedure code 85.21 is assigned for the lesion excisions and code 85.19 is assigned for the pre-op placement of the localization wire in the left breast.