Oncology & Hematology Coding Alert

Don’t forget to read inclusion terms carefully.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below.

Answer 1: Accurate coding for this first scenario depends on two things: whether your oncologist documents there is a link between the cancer and the fatigue, and whether you can correctly follow ICD-10-CM coding instructions.

If the oncologist’s documentation does not state a link between the two conditions, you would report the fatigue with R53.83 (Other fatigue). As this was the reason the patient reported to the provider, you would use the code as the principal diagnosis for the encounter.

However, if the oncologist links the cancer with the fatigue, you’ll use R53.0 (Neoplastic (malignant) related fatigue). But you will need to follow the instructions accompanying the code, which tells you to Code first the associated neoplasm. This means your first-listed diagnosis will be C92.00 (Acute myeloblastic leukemia, not having achieved remission) for the leukemia, followed by R53.0.

Answer 2: Coding in this scenario will be similar to the coding for the first scenario when the oncologist has determined the fatigue is related to the leukemia, with one important exception: You will need to code the patient’s anemia.

So, in addition to reporting C92.00 and R53.0, you’ll add D63.0 (Anemia in neoplastic disease) for the anemia caused by leukemia. And, as R53.0 and D63.0 both carry the same instructional note to code the associated neoplasm first, you’ll code C92.00 first, followed by D63.0 and R53.0.

Answer 3: In this scenario, you’ll have to account for the etiology of the anemia, which is the chemotherapy the patient is taking for the cancer. This means you’ll have to use two different codes: one for the anemia caused by the chemotherapy and one for the adverse effect of the chemotherapy.

Coding for this scenario will then look like this:

• D64.81 (Anemia due to antineoplastic chemotherapy) for the anemia
• T45.1X5- (Adverse effect of antineoplastic and immunosuppressive drugs) for the cause of the anemia, which is the chemotherapy treatment. Per the T45 category instructions, you’ll also add a 7th character A (initial encounter), D (subsequent encounter), or S (sequela), depending on the stage of patient care.
• C92.00 for the leukemia
• R53.83 for the fatigue

Why? In a similar coding scenario, AHA ICD-10-CM Coding Clinic 3rd Quarter 2021 tells you that D64.81 would be the principal diagnosis in this case. Additionally, “although there is an Excludes 1 note at category D64 (Other anemias), which means the two codes, D64.- and a code from C92.-, cannot be assigned together, both codes are required to capture anemia due to chemotherapy and acute myeloid leukemia. These are separate conditions, which are unrelated, as the anemia was caused by the chemotherapy not the AML, and thus they are an exception to the Excludes1 note,” according to Leah Fuller, CPC, COC, managing consultant, Pinnacle Enterprise Risk Consulting Services LLC, Charlotte, NC.

Answer 4: Even though symptoms such as malaise, exhaustion, lethargy, lack of energy, and so on may sound the same as fatigue in the medical record, they do not carry the same meaning in ICD-10-CM coding. This means you should be aware of the different R53.- (Malaise and fatigue) codes and their synonyms that may be at your disposal. They would include codes such as:

• R53.1 (Weakness), which has asthenia NOS as a synonym. Asthenia is a synonym for lack of strength.
• R53.81 (Other malaise), which has chronic debility, debility NOS, general physical deterioration, and malaise NOS as synonyms. Confusingly, debility is a synonym for weakness.
• R53.82 (Chronic fatigue, unspecified), which has chronic fatigue syndrome NOS as a synonym.
• R53.83, which has lack of energy, lethargy, and tiredness as synonyms.

A note about ICD-10-CM inclusion terms: “According to ICD-10-CM guideline I.A.11, the list of terms under a code are referred to as inclusion terms. They include synonyms for some codes and, when listed under an ‘other specified’ code, indicate conditions represented by that code,” says Fuller.

This means you should “always refer to the Alphabetic Index as a first step prior to consulting the Tabular List as the inclusion terms are not an exhaustive list and the Alphabetic Index can provide additional terms that will lead you to the appropriate code choice,” Fuller advises.

Most important: Ultimately, as with any coding scenario, provider documentation must drive your code choice. “If the provider’s documentation regarding the cause of the patient’s fatigue is unclear, you will need to have the provider clarify their findings. Do not assume causality before having the supporting definitive documentation in the patient’s record for the correct code choice,” Fuller notes.