Oncology & Hematology Coding Alert

And test your knowledge of testing techniques along the way.

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

Answer 1: One of the following lab tests will determine a patient’s estrogen receptor status:

• 84233 (Receptor assay; estrogen)
• 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure)
• 88360 (Morphometric analysis, tumor immunohistochemistry [eg, Her-2/neu, estrogen receptor/progesterone receptor],quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual)
• 88361 (... using computer-assisted technology)

Code choice will depend on whether the lab performs a simple assay (84233) or a qualitative (88342) or semi-quantitative/quantitative (88360/88361) analysis. For semi-quantitative/ quantitative testing, code choice will further depend on whether testing is manual (88360) or computer assisted (88361).

Lab results will appear as positive or negative, as a percentage (between 0 percent and 100 percent), or as a score:

• 0 for no receptors found
• 1+ for a small number of receptors found
• 2+ for a medium number
• 3+ for a large number

The American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) recommend designating a tumor as ER+ if at least one percent of the cells examined test positive. But your oncologist must be the one to make that judgement.

Answer 2: The following ICD-10-CM codes describe estrogen receptor status:

• Z17.0 (Estrogen receptor positive status [ER+])
• Z17.1 (Estrogen receptor negative status [ER-])

However, you will not simply submit a Z17.- code on its own.

A note with the Z17 codes states, “Code first malignant neoplasm of breast (C50.-).” ICD-10-CM rules state the “code first” instruction “directs the coder to sequence the underlying condition before the manifestation.” So, you must report the patient’s breast cancer before reporting the estrogen status.

Here’s how: First, you’ll review the patient’s chart for the location of the breast mass, and choose the appropriate C50.- code by location of the neoplasm: nipple and areola (C50.0-); central portion (C50.1-); upper/lower inner/outer quadrants (C50.2- through C50.5-); axillary tail (C50.6-); overlapping sites (C50.8-); and unspecified site (C50.9-).

Then, following the C50.- instructional note telling you to “Use additional code to identify estrogen receptor status (Z17.0, Z17.1),” you’ll add the appropriate Z17.- code secondary to the malignant neoplasm code.

Remember: “It is possible to have two masses in different locations of the breast, and when this occurs both breast cancer codes should be reported,” notes Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. So, for example you may report C50.211 (Malignant neoplasm of upper-inner quadrant of right female breast) and C50.412 (Malignant neoplasm of upper-outer quadrant of left female breast) together before adding the appropriate estrogen receptor status code.

Answer 3: Fulvestrant is used to treat advanced, HR+ breast cancer in women who have not received other medication for the condition and who are postmenopausal. Your oncologist will administer it as an intramuscular injection, which you will document with HCPCS Level II code J9395 (Injection, fulvestrant, 25 mg). You will also need to report administration code 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic).

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