Oncology & Hematology Coding Alert

And test yourself with these tricky scenarios.

Despite some difficult clinical terminology and a somewhat confusing grading system, coding leukemia, lymphoma, and myeloma doesn’t have to be intimidating. This guide breaks down the three major blood cancer types and identifies key concepts to demystify each one for you.

Along the way, we’ve added three short blood cancer vignettes, so you can put your newfound knowledge to the test.

Define the 3 Main Blood Cancers and Their Causes

To fight infections, the body produces white blood cells. When production of those cells goes out of control, the body is no longer able to fight infections effectively, and the following blood cancers can form:

• Leukemia, the “most common blood cancer for children under 15,” is classified as either lymphocytic (affecting the lymphocytes) or myeloid (affecting other immune cells). It can grow fast (acute) or slowly (chronic).
• Lymphoma affects lymphocytes, white blood cells produced in the lymphatic system, a part of the immune system. Lymphoma is classified as either Hodgkin (affecting the whole lymphatic system) or non-Hodgkin (affecting the lymph nodes or lymphatic tissue around the major organs).
• Myeloma affects cells in the plasma, or liquid, part of the blood (sources: www.yalemedicine.org/conditions/blood-cancers, www.lls.org/).

Learn how to Code for Leukemias

The basics: Leukemias are assigned to ICD-10-CM categories C91-C95, with a 4th character designating the disease type, such as adult T-cell, B-cell, hairy cell and so on, or stage.

What to watch for: Many of the leukemia codes take 5th characters indicating the status of the condition as not having achieved remission (5th character 0), in remission (5th character 1), or in relapse (5th character 2). To correctly assign the 5th character, or a “history of” code, you need to understand what the clinical definitions mean.

Remission can be either partial, where some of the signs and symptoms of the condition are still present, or complete, where all of the signs and symptoms have disappeared. In cases of partial remission, you will assign the 5th character 1 to the appropriate leukemia code; in cases of complete remission — if the malignancy has been eradicated without any evidence it still exists and/or the patient is not receiving any treatment for the leukemia — and if provider documentation supports it, you would then assign Z85.6 (Personal history of leukemia).

Before assigning a character for remission, however, you should follow the advice in ICD-10-CM guideline I.C.2.n, which says, “if the documentation is unclear as to whether the leukemia has achieved remission, the provider should be queried.”

Relapse means that signs and symptoms of leukemia have returned after a period in which the patient has been free of the disease. “Provider documentation will be key to determining the correct diagnosis code with the highest level of specificity,” says Leah Fuller, CPC, COC, a senior consultant with Pinnacle Enterprise Risk Consulting Services, LLC in Charlotte, NC.

Test Yourself

A provider documents that a patient with a personal history of adult T-cell leukemia, who has been symptom free for several years and has not received treatment for it in that time, now presents with a new onset of symptoms indicative of the condition once again.

In this scenario, you would use C91.52 (Adult T-cell lymphoma/leukemia (HTLV-1- associated), in relapse). This code would be more accurate than C91.50 (Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission) even though C91.50 lists adult T-cell lymphoma/leukemia (HTLV-1-associated) with failed remission as an inclusion term. That’s because failed remission implies the patient was never fully free of the condition or stopped receiving treatment for it. But before assigning C91.52, make sure the documentation and/or the physician query can support it.

Learn how to Code for Lymphomas

The basics: Lymphomas are assigned to C81-C88. They take 4th and 5th characters, with the 4th specifying disease type. Unlike leukemia, however, the 5th character specifies location, which is either a node or an anatomic region.

What to watch for: One category of lymphomas, C82.- (Follicular lymphoma), can present a particular coding problem. The confusion stems from the fact that the medical profession employs two different systems to classify condition severity (see https://emedicine.medscape.com/article/2007038-overview).

One system, the Cotswolds modification of the Ann Arbor staging system, breaks the condition down into stages, which describe the areas of lymph node involvement (stages I-IV), symptoms (stages A/B) and other factors (X, E).

The second system, the World Health Organization (WHO) classification, breaks the condition down by grades: I, II and III (unspecified), IIIa, and IIIb. The system determines the grade by counting the average number of centroblasts (CBs) in a microscopic high-power field (HPF). Grades I (0-5 CB/ HPF) and II (6-15 CB/HPF) are generally regarded as low risk, while grade III (>15 CB/HPF) is seen as high risk. The difference between grades IIIa and IIIb lies in the absence (IIIa) or presence (IIIb) of centrocytes.

It is this second system that ICD-10-CM employs in its diagnosis coding.

Test Yourself

A patient is diagnosed with follicular lymphoma. The patient reports sudden weight loss of over 10 percent. Test results reveal multiple affected lymph nodes on the same side of the patient’s diaphragm and a CB/HPF of 10.

While the patient’s symptoms are important, for coding purposes, the location of the affected nodes and the CB/HPF measurement in the note are the significant pieces of information, leading you to code C82.12 (Follicular lymphoma grade II, intrathoracic lymph nodes).

Learn how to Code for Myeloma

The basics: The myeloma codes are located in the C90.- (Multiple myeloma and malignant plasma cell neoplasms).

What to watch for: First, while it may sound similar, do not confuse myeloma with myeloid leukemia, which is coded to C92.- (Myeloid leukemia).

Second, like leukemia, when a patient is in complete remission for multiple myeloma, you will use a personal history code if the documentation and/or provider query support it, though this time, instead of Z85.6, you’ll use Z85.79 (Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues), “making sure you follow the tabular notes for the specific code and the notes to parent code Z85.- [Personal history of malignant neoplasm], advises Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

Test Yourself

A patient reports back to your office several weeks after undergoing a course of treatment for solitary myeloma. The provider’s notes indicate that many of the patient’s symptoms have now disappeared, and the patient is in partial remission. For this encounter, you can go ahead and code C90.31 (Solitary plasmacytoma in remission).

“Be sure to look out for the many Excludes notes, Includes notes, inclusion terms, Code also, and etiology/manifestation conventions throughout code categories C81-C95 for further guidance with blood cancer coding,” Fuller adds.