Oncology & Hematology Coding Alert

If you-re occasionally overwhelmed trying to find an appropriate neoplasm diagnosis, take heart: With the pathology report, a current ICD-9 manual and our expert advice at hand, you can nail the appropriate code without fail.

Step 1: Don't Make a Move Without the Path Report

You shouldn't even try to choose a neoplasm diagnosis until you-ve received the results of the pathology study, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.

"Without the pathology report, you-re just guessing what kind of neoplasm you-re dealing with," she adds. And entering a wrong diagnosis can have serious effects.

You don't want to label a patient as having cancer if the diagnosis isn't certain. A cancer diagnosis is a red flag for insurers that could make gaining medical coverage more difficult for the patient.

At the same time, if you fail to indicate a malignant lesion (when present), you limit the treatment options that the insurer may accept at a later date.

Bottom line: Choosing a diagnosis is hard enough, so be sure you have all the relevant information before you proceed.

 
Step 2: Identify Neoplasm Type

With the pathology report in hand, you should be able to determine if the neoplasm is benign or malignant. The neoplasm table in ICD-9-CM further classifies malignant and benign neoplasms into various subclassifications, as follows:

Primary: A primary malignancy arises from the stated or presumed site or origin, Bucknam says.

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

Secondary: 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 (direct extension).

For example, if pathology indicates that a lump from the chest wall beneath a previous mastectomy is a secondary malignancy of a lymph node, you would report 196.3 (Secondary and unspecified malignant neoplasms of lymph nodes; lymph nodes of axilla and upper limb).

Warning: You should not report a "recurrence" of the same cancer as a secondary malignancy.

In situ: "In situ" describes malignancies confined to their site of origin. Although such neoplasms have not yet invaded neighboring tissues, they can grow large enough to cause major problems, and may become invasive.

Tip: "In situ" is a histopathological classification. Therefore, you would report these codes only if the pathology report or oncologist states that the malignancy is "in situ," says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and past president of the American Academy of Professional Coders National Advisory Board.

When pathology does not confirm evidence of cancer, you should choose from the following:

Benign: Benign neoplasms are cancer-free. For example, for a non-invasive breast fibroadenoma, you-d report 217 (Benign neoplasm of breast).

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 become malignant, Bucknam notes.

Unspecified: You should use this category only when you have no indication of the neoplasm's nature. In other words, an "unspecified" code means there is not enough information in the medical record to make a determination.

Do not confuse "uncertain" with "unspecified": "An -unspecified- code typically means that there was incomplete diagnosis information listed in the medical record," Parman says. "Also, a coder will never go the neoplasm table and select a code from either the -uncertain behavior- or -unspecified nature- columns -- instead, they will look up the name of the tumor or available diagnostic information in the alphabetic index, which will direct them to the appropriate column in the neoplasm table."

For example, if the coder looks up "tumor" in the ICD-9-CM alphabetic index, it states, "See also: Neoplasm, by site, unspecified nature."

Step 3: Consult ICD-9-CM, Vol. 2

Next, you should go to the ICD-9-CM manual's alphabetic index (Vol. 2) and look up the main term that describes the neoplasm type.

Don't skip to the neoplasm table: Although the alphabetic index often directs you to the neoplasm table, checking the index is not a wasted step.

You won't find all the codes you need in the neoplasm table. ICD-9-CM lists certain conditions only in the index. In other cases, the index saves time and reduces confusion.

Caveat: "The coder will generally go directly to the neoplasm table if it is a malignancy. Otherwise, we need to check the alphabetic index to know which column in the Table to review," Parman says.

Example: If you look up "malignant melanoma of the lip" in the alphabetic index, you will find 172.0 (Malignant melanoma of skin; lip). In this case, you do not need to consult the neoplasm table elsewhere in Vol. 2 -- although you should still confirm the code by checking it against the tabular index (ICD-9-CM, Vol. 1).

If the alphabetic index doesn't provide the information you need, you should next consult the neoplasm table.

For example, if you look for "adenoma" in the ICD-9-CM index, the entry will direct you to the neoplasm table, stating, "See also: Neoplasm, by site, malignant."

In a second example, if you look for "rectal adeno-carcinoma" in the index, you-ll find directions to "Neo-plasm, by site, malignant." You then look for "rectum" in the neoplasm table. Consulting the pathology report, you notice the neoplasm is in situ, and you therefore report 230.4 (Carcinoma in situ of digestive organs; rectum).

Skin and breast lesions require special consideration: For neoplasms that occur on or near the skin of an anatomic site, you should assign a diagnosis for skin -- not for the body area in question -- Bucknam notes.

Also, if you find "breast" in the neoplasm table, you will notice that the codes are further differentiated according to the exact breast area and the type of malignancy. For instance, you would report primary malignancy of the lower-inner quadrant using 174.3.

Always check the tabular list: In all cases, before assigning a final code, verify the diagnosis you have selected in ICD-9-CM's tabular list (Vol. 1).

A final tip: "Never use a -.9- diagnosis code," Parman advises. "If we are treating a lesion or body area with chemotherapy or radiation therapy, we should know exactly where the lesion, tumor or neoplasm is located."

The use of multiple ".9" diagnosis codes (such as 162.9, Lung cancer, unspecified) may be an audit trigger, Parman warns.