General Surgery Coding Alert

Our primer makes deciphering the path report easier
 
The many categories of neoplasms can be confusing, but a quick review of the relevant terminology can clear up any doubts you may have about your coding choices.

Malignant and Benign Define Main Categories

When looking at the neoplasm table, you will notice two main categories of neoplasm: malignant and benign, with three subcategories for malignant, as follows:

Primary. A primary malignancy is one arising from the cells found where the neoplasm was biopsied, explains Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM Program Coordinator at Clarkson College in Omaha, Neb.

For example, if a female patient has a breast lump in the lower-inner quadrant that is malignant and comprised of cancer cells from the area of excision (as opposed to cancer cells that originated elsewhere and spread to the breast), you should code for a primary malignancy (174.3).

Secondary. You should use these codes when the neoplasm is the result of metastasis and forms a new focus of malignancy elsewhere, such as the lymph nodes, liver, lungs or brain or when the primary cancer has invaded adjacent structures.

For example, if the surgeon removes a lump from the chest wall beneath the previous mastectomy and the pathology report indicates that the lump is a secondary malignancy with the breast as the origin, you should report a secondary neoplasm code (198.89).
 
In Situ. In situ describes malignancies confined to the site of origin without invasion of neighboring tissues, although they can grow large enough to cause major problems, Bucknam says. In some cases, however - such as those involving the breast (233.0), bladder (233.7) and cervix (233.1), for instance - there is no guarantee that removal of the mass will totally eradicate the cancer.

No Cancer = No Malignancy

If pathology does not find evidence of cancer, you should not report a malignant ICD-9 code. Instead, choose from the following three categories:

Benign. Benign neoplasms are cancer-free. For example, for a fibroadenoma of the breast, which does not spread, report a benign neoplasm (217). Benign neoplasms may return after removal, but they are non-invasive, Bucknam explains.

Uncertain Behavior. If the pathology report returns with indications of atypia or dysplasia, the neoplasm is "in transition" from benign to malignant. If the process continues and the mass is left untreated, the neoplasm could eventually become malignant.

For example, benign adenomatous polyps are at high risk for becoming malignant if they remain undiagnosed and untreated.

Do not confuse "uncertain" with "unspecified." "A pathologist makes the 'uncertain' determination based on analysis," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Landsdale, Pa. If the pathologist labels the neoplasm uncertain, you shouldn't use an unspecified diagnosis, because "unspecified" implies that the surgeon's documentation didn't indicate the skin lesion's type.

Unspecified. This category should be used only when the surgeon cannot determine the nature of the neoplasm. If the surgeon excises a lipoma but does not wait for the pathology report, for example, these are the only codes that should be used.