ICD 10 Coding Alert

Histology, sequencing, and site key to specificity.

New and veteran coders in different specialties will probably agree that the Table of Neoplasms in ICD-10-CM is one of the most useful tools at their disposal. But no matter how familiar you are with using it, there are always new tricks and tips you can learn. Here are a few of them, along with some examples to make your neoplasm coding faster and more accurate.

Look to Neoplasm Table First

To locate the appropriate code in the Neoplasm Table, you'll need to know the anatomical site affected and whether the neoplasm is malignant (secondary, primary, or Ca in Situ), benign, uncertain behavior, or unspecified behavior.

Once you locate the suggested ICD-10-CM code in the Neoplasm Table, you will need to verify it is the correct choice in the Tabular List. Checking the code against the Tabular List provides guidance on laterality, site location, gender, whether you need to use an additional code to report your patient's condition, as well as any excludes notes that may be applicable.

Tip: If you know the histological term for the neoplasm, such as "adenocarcinoma" or "myolipoma," you can look it up in the Alphabetic Index and note the code and any other instructions before checking your code against the Neoplasm Table. This way you can determine which column in the Neoplasm Table is appropriate for the patient's diagnosis.

There are certain histological terms that include the correct codes in the Alphabetical Index and do not refer to the Neoplasm Table. Examples include melanoma, skin and Merkel cell carcinoma. So, if the histological term is noted by the physician, always check the Alphabetical Index first, says Lisa  Selman-Holman,  JD,  BSN,  RN,  COS-C,  HCS-D,  HCS-O,  AHIMA  Approved  ICD-10-CM  Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR - Coding Done Right and Code Pro University in Denton, Texas.

Remember this Sequencing Rule

When coding for a neoplasm that has metastasized to a secondary site, you'll usually code the primary site before the metastasis.

Exception: As is the case with most rules in healthcare, there is an exception to the typical process you'll need to understand. If the secondary site is the focus of care, or if the primary site has been resolved, you can code for the metastasis first, according to the ICD-10-CM Official Guidelines Section I.C.2.

Take Note of Site Guidance

When coding for a malignant neoplasm that overlaps two or more contiguous sites, you'll report the "multiple sites" code ending with character "8" in most cases. For example, C00.8 (Malignant neoplasm of overlapping sites of lip).

But when a patient has multiple neoplasms of the same site that aren't next to each other, such as tumors in different quadrants of the same breast, you'll assign codes for each affected site.

Coding  example: Your 74-year-old female patient has unresolved small cell carcinoma of the right lower lobe of the lung with metastasis to the intrathoracic lymph nodes, brain, and right rib.

Code for this patient's diagnoses as follows, says Judy Adams,  RN,  BSN,  HCS-D,  HCS-O, with Adams Home Care Consulting in Asheville, N.C.:

• C34.31 - Malignant neoplasm of lower lobe, right bronchus or lung;
• C77.1 - Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes;
• C79.31 - Secondary malignant neoplasm of brain; and
• C79.51 - Secondary malignant neoplasm of bone.

To begin coding for this patient, you can start with the Alphabetic Index, because you know the histological term - "Carcinoma." The Alphabetic Index will refer you to the Neoplasm Table, by site, malignant.

The neoplasm of the primary site is unresolved in your patient's situation, so you'll list this code first, Adams says. Next, list the secondary sites. These areas aren't contiguous, so you'll list a code for each site.

The sequencing of the secondary metastasis codes should be based on your plan of care, so if C79.51 is your second code listed because the patient's metastasis to the bone is causing tremendous pain, then sequence it second, says Selman-Holman. And if that's the case, add G89.3 (Neoplasm related pain [acute] [chronic]).

Tricky: Codes for neuroendocrine tumors, which are often seen in hospice patients, are difficult to find when verifying the code because the code looks different than the other neoplasm codes. For example, C7A.090 (Malignant carcinoid tumor of the bronchus and lung) has an "A" as its third character, rather than a number like the other neoplasm codes. If you're having difficulty finding a code in the Tabular List, go to the beginning of the chapter and review the list of broad groups of neoplasms, she suggests. "This defines the different grouping of the codes within the chapter." And you'll see that the C7A codes follow C73-C75.

Another example: How would you code for the diagnosis "benign carcinoid of the jejunum?"

Look up the term "carcinoid" in the Alphabetic Index, since you know the morphology of this patient's neoplasm, Adams says. You'll be directed to "see Tumor, carcinoid." When you look under "Tumor, carcinoid," you'll find that the codes are divided up between benign and malignant, and categorized by site.

Look under "Tumor, carcinoid, benign, jejunum," and you'll be directed to code D3A.011. Check this code in the Tabular List and you'll see notes directing you to "Code also any associated multiple endocrine neoplasia [MEN] syndromes (E31.2-)" and "Use additional codes to identify any associated endocrine syndrome, such as: Carcinoid syndrome (E34.0)." Your diagnosis code for this patient is D3A.011 (Benign carcinoid tumor of the jejunum).