Oncology & Hematology Coding Alert

You may need to apply new-for-2006 demonstration project and neutron treatment codes

April is a great time to jump to the head of the head and neck cancer coding class because April 17-23 is Oral, Head, and Neck Cancer Awareness Week.

Head and neck cancer includes cancer of the lips, oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity, ear, and salivary glands, but not the brain.

The diagnosis codes you-re most likely to use include the following:

- 140.x--Malignant neoplasm of lip
- 141.x--Malignant neoplasm of tongue
- 142.x--Malignant neoplasm of major salivary glands
- 143.x--Malignant neoplasm of gum
- 144.x--Malignant neoplasm of floor of mouth
- 145.x--Malignant neoplasm of other and unspecified parts of mouth
- 146.x--Malignant neoplasm of oropharynx
- 147.x--Malignant neoplasm of nasopharynx
- 148.x--Malignant neoplasm of hypopharynx
- 160.x--Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
- 161.x--Malignant neoplasm of larynx.

Note: Remember to report the most specific diagnosis code possible. Your ICD-9 manual instructs you to code each of these ranges to the fourth digit. Translation: Your documentation shows a primary diagnosis of a base-of-tongue malignant neoplasm. Report 141.0 (Malignant neoplasm of tongue; base of tongue), not 141 (Malignant neoplasm of tongue).

Assign code 195.0 (Malignant neoplasm of other and ill-defined sites; head, face, and neck) when your physician documents a primary-site head and neck malignant neoplasm but he can't determine the point of origin.

Determine Need for V or E Code

Patients may develop head and neck cancers after exposure to certain carcinogens.

Physician documentation rarely shows a definitive link between a specific external cause and the cancer, says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, president of MJH Consulting in Denver.

Your physician may decide to document a history of exposure to a hazardous substance, instead.

Example 1: You-re filing a workers- compensation claim. The physician documents that a neck cancer patient has a history of asbestos exposure due to his work in construction. You report V15.84 (Exposure to asbestos) along with the other appropriate ICD-9 and CPT codes to paint a complete picture for the payer.

Example 2: Your physician documents that the patient received radiation treatment for a previous, unrelated cancer. You report V15.3 (Other personal history presenting hazards to health; irradiation).

If--and only if--your physician specifically documents a link between a hazardous substance and the cancer, you may indicate this connection with the proper E code, Hammer says.

Example: Your physician documents that a patient's tumor is the late effect of accidental exposure to radiation. You have the option of reporting E929.8 (Late effects of other accidents).

Don't stress: Reporting E codes is usually elective because payers consider E codes to be supplementary to the ICD-9 diagnosis codes, Hammer says. Exception: You-re required to report the causative substance for an adverse effect of a drug, medicinal, or biological substance, correctly prescribed and properly administered.

The ICD-9 Guidelines provide the directions for E code use, Hammer says. Find the most recently released
guidelines at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide05.pdf.

Rev Up Your Radiation Treatment Coding

Radiation treatment for head and neck cancer includes IMRT and neutron beam radiation.

IMRT: Payers may cover IMRT for certain head and neck cancer diagnoses, including naso-pharyngeal carcinoma (such as 230.0, Carcinoma in situ of digestive organs; lip, oral cavity, and pharynx).

Why: IMRT's conformal radiation planning and delivery target the lesion better than standard techniques, sparing surrounding normal tissue and limiting side effects, such as xerostomia.

When coding IMRT for head and neck cancers, report 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications) for the treatment planning. For delivery, report 77418 (Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session).

Remember: For compensator-based IMRT, report 0073T (Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high-resolution [milled or cast] compensator convergent beam modulated fields, per treatment session) along with 77301 for treatment planning.

You-re most likely to see your physician document IMRT with diagnoses including cancer of the tongue (141.x), oropharynx (146.x), and nasopharynx (147.x). Your oncologist may also use IMRT to treat a carcinoma in situ of the mouth or pharynx (230.0).

Neutron beam radiation: Your radiation oncologist may treat a patient with salivary gland tumors (142.x) using neutron beam radiation, although neutron treatment is rare because it is so expensive.

For services performed before Jan. 1, 2006, you reported a radiation treatment delivery code from the 77412-77416 range, says Pamela Moore, CPC, Moll Cancer Center patient representative in Cleveland.

CPT added codes specifically for neutron beam treatment delivery in 2006, she says:

- 77422--High-energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking

- 77423---1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s).

Don't Forget the 2006 Demonstration Project

If your oncologist provides an E/M service (levels two-five) for an established patient, remember that you can earn an extra $23 by reporting the appropriate 2006 demonstration G codes.

Patients are eligible for the project based on diagnosis, says Linda Gledhill, MHA, senior associate with oncology consulting firm ELM Services Inc., based in Rockville, Md.

A patient with head and neck cancer must have a primary diagnosis of 140.0-149.9 or 161.0-161.9 to be eligible for the project.

You must report one code from each of three categories: G9050-G9055 (Oncology; primary focus of visit ...), G9056-G9062 (Oncology; practice guidelines ...), G9063-G9130 (Oncology; disease status ...). You can download the G codes at www.cms.hhs.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp.

Tip: Make things easier on yourself--use the American Society of Clinical Oncology's documentation templates, available at www.asco.org. Click on each of these links in succession to find the templates:

- Legislative and Regulatory
- Legislative and Regulatory Issues
- Policy Issues
- Medicare and Quality Care
- MMA Regulation & Resources.