Ob-Gyn Coding Alert

"When coding for the diagnosis of breast or genitourinary cancers, ICD-9 offers only a few optionsthere are essentially three sets of codes from which to choose. Sounds pretty simple, but understanding the definitions of these types of cancer and the intent of the code is another story.

At the recent CodingFest 2000 coding conference in Florida, Stephanie L. Jones, NRCMA, NRCAHA, CPC, an independent coding consultant, presented a workshop on cancer coding. A lively debate ensued over which codes to assign for which kinds of cancer tumors. The gist of the dilemma dealt with the three main categories of ICD-9 codes for cancer tumors. Some members of the audience were adamant that a cancer tumor, no matter how small or how large, if confined to the organ where it originated, was always coded carcinoma in situ. In their view, primary carcinoma is to be used only when a secondary carcinomai.e., a metastasis to another organ other than the organ of originis also present. Their contention was that a primary code could never be used if there was not also a secondary cancer code reported on the claim form.

In contrast, about half of the audience said their clinics coded a single tumor confined to the organ of origin as primary whether or not there was a secondary carcinoma, i.e., a metastasis to another organ. They also felt that carcinoma in situ was much more narrowly defined in the medical dictionary as a tiny spot of cancer that had not broken through its surrounding tissue. Thus there is a breast biopsy diagnosis for ductal carcinoma in situ, which can mean just watchful waiting or a lumpectomy for the patient, rather than a radical mastectomy as might be the case with an invasive, primary or secondary breast cancer.

Numerous coders stated they were aware of the term carcinoma in situ, perhaps most popularly associated with ductal carcinoma in situ for mammograms with follow-up biopsies, and cervical carcinoma in situ for Pap smears with cervical biopsies. But, they felt the term was usually reserved for small, pre-invasive lesions not qualifying as full-fledged primary neoplasms. The level of disagreement and confusion over the subject was strong enough to motivate Ob-Gyn Coding Alert and Jones to review the rules and definitions for cancer coding for ob/gyn.

Understanding and Coding Stages of Neoplasms

Because of the controversy surrounding this topic, says Jones, I wanted to fill in the details and figure out which school of thought was corrector closest to being correct. I wanted to get clarification from a bonafide source, so I went to the World Health Organization, which referred me the National Cancer Institute (NCI) of the National Institutes of Health (NIH). I also have documentation from several other sources that defines some of what we were all looking for.

At NCI, Jones presented the debate to April Fritz, CTR, RHIT, technical information specialist. Fritz concluded that both sides of the debate were partially correct and explained some of the technical points of using ICD-9 codes, specifically for breast tumors.

Basically what she told me, says Jones, was that both sides were correct to a certain extent. From an ICD-9 coding perspective, the definition of an in situ neoplasm is a tumor that has not extended through the basement membrane of the epithelium or remains encapsulated within a duct. Jones also learned that an in situ tumor can be diagnosed only microscopically. Only a pathologist can tell whether the tumor has penetrated the basement membrane, says Jones, and only if the pathologist indicates that the tumor is in situ would you use the 230-234 (carcinoma in situ) codes. If there is even one cell of invasion, you would use the primary codes 140-195 (malignant neoplasms, stated or presumed to be primary, of specified sites, except of lymphatic and hematopoietic tissue). Once the tumor has spread beyond the primary organ, you would also code the secondary site(s) with 196-198 (malignant neoplasms, stated or presumed to be secondary, of specified sites).

Ms. Fritz explained in very general terms, Jones continues, to use codes 140-195 for a primary organ tumor unless the pathologist says it is in situ. Be aware that in situ has several synonyms: intraepithelial, intraductal, Stage 0, noninfiltrating, noninvasive and others. But the pathology report remains the driving force in making determination of the correct ICD-9 code to use.

Who Reads the Pathology Report?

When asked for her input, Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator, said she shuddered at the idea of a coder interpreting a pathology report. It is never correct for a coder to read the pathology report and code from it unless the coder has had special training or the diagnosis given by the pathologist is unambiguous, says Witt.
Essentially, that means they are diagnosing the patient. And sometimes, the pathologist does not know whether a cancer will turn malignant or not, so they might write something like uncertain behavior. When the pathologist uses ambiguous terms like that, it is definitely the job of the patients physician or clinician to determine the diagnosis.

After the doctor reads the pathology report, he or she should spell out in plain language what the diagnosis is, including using the terms primary, secondary and in situ if applicable, so the coder knows exactly which codes to apply. If the doctors notes are not clear, says Witt, the coder needs to go back and clarify with the doctor. But the physician absolutely has to see the pathology report first and then write his or her diagnosis.

Sequencing Is Important

While I believe that the issue of whether a cancer is in situ or an invasive cancer is usually fairly straightforward once the pathology report has been received, another issue that is frequently lost in the debate of what cancer code to use is the answer to the question Why is the patient seeking care today?, says Witt. I have discussed this issue many times with the National Center for Health Statistics (NCHS) ICD-9 coding staff for coding questions that needed clarification, and the answer was always the same. In cancer coding, as in any other type of condition, coding for outpatient services means coding the most specific reason for the service or procedure rendered at this encounter, based on what you know at the end of the encounter. That is, reporting the ICD-9 code that justifies the purpose of the encounter.

Witt offered the example of the patient who has both a primary site tumor and a secondary metastatic tumor, but the reason for the encounter is the treatment of the metastatic tumor. In this encounter, the metastatic tumor becomes the primary or first diagnosis. Coders might also want to code the location of the primary site tumor, but that code would be listed second on the claim form. NCHS also clarified to Witt that if the patient has two types of cancer, one invasive and one in situ in the same organ, the most severe type of cancer would be coded and the in situ would not be coded at all. This unusual condition would probably only occur with breast cancer, where the patient has carcinoma in situ of the right breast, but invasive cancer of the left breast. ICD-9 cannot differentiate between the two breasts, so only the invasive cancer would be coded. This particular problem will be resolved in ICD-10, according to NCHS ICD-9 coding staff. Even this example is not necessarily the last word because if the reason for the encounter was the treatment of the in situ cancer and not the invasive cancer, the correct diagnosis would be carcinoma in situ of the breast, 233.0.

Coding for breast and genitourinary cancers using three basic sets of codes is not as basic as it might initially appear. Familiarizing oneself with carcinoma terminology, as well as working closely with physicians and/or other medical staff in understanding cancer definitions, will ensure accurate coding.
 

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