Oncology & Hematology Coding Alert

Here’s why you need to look up your code in the tabular index of your ICD-10 manual.

Even if you think you’re an expert when it comes to neoplasms or you’re new to oncology, refreshing your Table of Neoplasms skills could spare you frustration down the line. Start the new year with some new tricks and tips to speed up your diagnosis coding.

Get to Know Your Neoplasm Table

To locate the appropriate code in the Neoplasm Table, you’ll need to know the anatomical site affected and whether the neoplasm is malignant (secondary, primary, or Ca in Situ), benign, uncertain behavior, or unspecified behavior.

Once you locate the suggested ICD-10-CM code in the Neoplasm Table, you will need to verify it is the correct choice in the Tabular List. Checking the code against the Tabular List provides a more complete picture of the code and guidance on laterality, site location, gender, whether you need to use an additional code to report your patient’s condition, as well as any excludes notes that may be applicable. Once you’re located the code you may use, always look up the code in the tabular section of the ICD-10-CM text.

Tip: If you know the histological term for the neoplasm, such as “adenocarcinoma” or “myolipoma,” you can look it up in the Alphabetic Index and note the code as well as any other instructions before checking your code against the Neoplasm Table. This way you can determine which column in the Neoplasm Table is appropriate for the patient’s diagnosis.

There are certain histological terms that include the correct codes in the Alphabetical Index and do not refer to the Neoplasm Table. Examples include melanoma, skin and Merkel cell carcinoma. So, if the histological term is noted by the physician, always check the Alphabetical Index first, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR - Coding Done Right and Code Pro University in Denton, Texas.

Follow This Sequencing Rule

When coding for a neoplasm, metastasized to a secondary site, you’ll usually code the primary site before the metastasis.

Exception: As is the case with most rules in healthcare, there is an exception to the typical process you’ll need to understand. If the secondary site is the focus of care, or if the primary site has been resolved, you can code for the metastasis first, according to the ICD-10-CM Official Guidelines Section I.C.2.

Take Note of Site Guidance

When coding for a malignant neoplasm that overlaps two or more contiguous (‘next to each other’) sites, you’ll report the “overlapping lesion” code ending with character “8,” unless the combination is specifically indexed in ICD-10-CM elsewhere. For example, C00.8 (Malignant neoplasm of overlapping sites of lip).

When a patient has multiple neoplasms of the same site that aren’t next to each other, such as tumors in different quadrants of the same breast, you’ll assign codes for each affected site.

Coding example: Your 74-year-old female patient has unresolved small cell carcinoma of the right lower lobe of the lung with metastasis to the intrathoracic lymph nodes, brain, and right rib.

Code for this patient’s diagnoses as follows:

• C34.31 (Malignant neoplasm of lower lobe, right bronchus or lung)
• C77.1 (Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes)
• C79.31 (Secondary malignant neoplasm of brain) and
• C79.51 (Secondary malignant neoplasm of bone).

To begin coding for this patient, you can start with the Alphabetic Index, because you know the histological term – “Carcinoma.” The Alphabetic Index will refer you to the Neoplasm Table, by site, malignant.

The neoplasm of the primary site is unresolved and treatment is focused on the primary site in your patient’s situation, so you’ll list this code first. Next, list the secondary sites. These areas aren’t contiguous, so you’ll list a code for each site.

The sequencing of the secondary metastasis codes should be based on your plan of care, so if the patient’s metastasis to the bone is causing tremendous pain, then sequence C79.51 second, says Selman-Holman. And if that’s the case, add G89.3 (Neoplasm related pain [acute] [chronic]).

Tricky: Codes for neuroendocrine tumors, which are often seen in hospice patients, are difficult to find when verifying in the Tabular list because the code looks different than others in the neoplasm section. For example, C7A.090 (Malignant carcinoid tumor of the bronchus and lung) has an “A” as its third character, rather than a number like the other neoplasm codes. If you’re having difficulty finding a code in the Tabular List, go to the beginning of the chapter and review the list of broad groups of neoplasms, she suggests. “This defines the different grouping of the codes within the chapter.” And you’ll see that the C7A codes follow C73-C75.

Example: How would you code for the diagnosis “benign carcinoid of the jejunum?”

Look up the term “carcinoid” in the Alphabetic Index, since you know the morphology of this patient’s neoplasm. You’ll be directed to “see Tumor, carcinoid.” When you look under “Tumor, carcinoid,” you’ll find that the codes are divided up between benign and malignant, and categorized by site.

Look under “Tumor, carcinoid, benign, jejunum,” and you’ll be directed to code D3A.011. Check this code in the Tabular List and you’ll see notes directing you to “Code also any associated multiple endocrine neoplasia [MEN] syndromes (E31.2-)” and “Use additional codes to identify any associated endocrine syndrome, such as: Carcinoid syndrome (E34.0).” Your diagnosis code for this patient is D3A.011 (Benign carcinoid tumor of the jejunum).