# sequence coding for Neoplasms



## cld (Oct 30, 2008)

Is there an easy way to remember which code is listed as the principle code when you have a metastasis from the primary tumor. It seems the sequence rules change depending on the situation. I do coding for hosptialists, and they just write down codes in any order they want to from day to day.
Thanks for your help. Your advice has always been very helpful.
cld


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## magnolia1 (Oct 30, 2008)

Refer to the 2007, Fourth Quarter Coding Clinic below (this is what I would follow):


Chapter 2: Neoplasms (140-239)


General guidelines


Chapter 2 of the ICD-9-CM contains the codes for most benign and all malignant neoplasms.  Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters.  To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior.  If malignant, any secondary (metastatic) sites should also be determined.


The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. For example, if the documentation indicates "adenoma," refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to "see also neoplasm, by site, benign."  The 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. The tabular should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.


See Section I. C. 18.d.4. for information regarding V codes for genetic susceptibility to cancer.


a. Treatment directed at the malignancy


If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.


b. Treatment of secondary site


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


Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:


1) Anemia associated with malignancy


When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code 285.22, Anemia in neoplastic disease) is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy.


Code 285.22 may also be used as a secondary code if the patient suffers from anemia and is being treated for the malignancy.


2) Anemia associated with chemotherapy,immunotherapy and radiation therapy


When the admission/encounter is for management of an anemia associated with chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by code E933.1.  The appropriate neoplasm code should be assigned as an additional code.


3) Management of dehydration due to the malignancy


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) Treatment of a complication resulting from a surgical procedure


When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.


d. Primary malignancy previously excised


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. Admission/Encounter involving chemotherapy, immunotherapy and radiation therapy


1) Episode of care involves surgical removal of neoplasm


When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the neoplasm code should be assigned as principal or first-listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.


2) Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy


If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code V58.0, Encounter for radiation therapy, or V58.11, Encounter for antineoplastic chemotherapy, or V58.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.  If a patient receives more than one of these therapies during the same admission, more than one of these codes may be assigned, in any sequence.


3) Patient admitted for radiotherapy/chemotherapy and immunotherapy and develops complications


When a patient is admitted for the purpose of radiotherapy, immunotherapy 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 V58.11, Encounter for antineoplastic chemotherapy, or V58.12, Encounter for antineoplastic immunotherapy, followed by any codes for the complications.


f. Admission/encounter to determine extent of malignancy


When the reason for admission/encounter 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 associated with neoplasms


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.


See Section I.C.18.d.14, Encounter for prophylactic organ removal.


h. Admission/encounter for pain control/management


See Section I.C.6.a.5 for information on coding admission/encounter for pain control/management.




© Copyright 1984-2008, American Hospital Association ("AHA"), Chicago, Illinois.  Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.


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## rcbaker (Feb 2, 2009)

*Neoplasm coding*

patient presents to the radiation therapy depart. she was diagnosed with uterine cancer 6 years ago and successfully underwent a hysterectomy. she had chemo for 6 months and had remained cancer free for 4 years. she was recently found to have metastasis to the brain and presents for external radiation therapy. i coded v58.0 and 191.9 is this correct?


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## OliviaPrice (Feb 2, 2009)

*Neoplasm Coding*

You will always code first the area you are currently treating.  So for a patient who has a history of uterine cancer, with brain mets, receiving Radiation therapy I would code as such:
1) 198.3
2) V10.42 (If the patient has not received any treatment including oral meds for the uterine Ca in the past year)
3)V58.0

The Dx code 191.9 says this is a primary brain tumor not a metastatic tumor.  If this truly is mets from the uterine cancer you should use the secondary code of 198.3

Hope this helps!


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## rcbaker (Feb 3, 2009)

*neoplasm*

first thank you for your help.

Question: since the presenting for external radiation therapy, you don't sequence the V58.0 first?
V58.0
198.3
V10.42


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## OliviaPrice (Feb 3, 2009)

I am located in Kansas and our local carrier does not want any V codes listed as the principal Dx unless it is the only diagnosis available to use for that claim.  I have found that I have much better luck with all carriers when I do not list the V code first.  But it really is up to your local carriers and what they would prefer.


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## rcbaker (Feb 3, 2009)

*coding question*

thanks


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## mitchellde (Feb 4, 2009)

Sorry but the V58.0 code is first listed only and must go there, payers may not dictate that no Vcodes may be used first-listed.  The placement of V codes is driven by the Guidelines for coding and reporting as published by the CDC.  So for this scenario the V58.0 is first-listed always fowed byt the reason for the radiation , in this case the metastatic code and then code for the primary site, which in this care is the V code for history of the neoplasm.
Debra Mitchell, MSPH, CPC-H


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