Oncology & Hematology Coding Alert

Here’s how National Coverage Determination (“NCD”) guidelines can influence your code selection.

You may be an expert when it comes to coding surgical or imaging services, but if you’re not capturing the correct ICD-10-CM code, your claim could land in limbo.

Check out these two clinical encounters requiring more than just the ICD-10-CM index to get it right. As you’ll see, you’ll have to gather intel from some unlikely places in order to maximize your chances of success.

Be the best coder you can be by giving these two challenging diagnostic scenarios a try.

Make Use of All Your Coding Resources

Diagnosis: Pancreaticobiliary Cancer

The first point you’ll want to address is the behavior of the neoplasm. Despite the fact that the diagnosis does not document “benign” versus “malignant” behavior, the reference of “cancer” tells you all you need to know. Cancer, by definition, cannot be benign, so you know you are going to be coding a malignant neoplasm.

Next, you’re going to address the anatomic locations outlined in the diagnosis. In some instances, the Table of Neoplasms allows for one code to represent overlapping malignant sites. In other instances, you’ve got to report each separately. The documented diagnosis identifies a malignant neoplasm of two sites — the pancreas and the biliary tract (or system). The term biliary, according to Dorland’s Illustrated Medical Dictionary, pertains to “the bile, bile ducts, or gallbladder.” While you may be able to infer that pancreatobiliary cancer is most likely a malignant neoplasm of the pancreas that overlaps on to the connecting portion of the bile duct, you cannot make this assumption as a coder.

Instead, your only option is to report two separate diagnosis codes since the term “Pancreatobiliary” does not exist within the ICD-10-CM Table of Neoplasms. For a malignant neoplasm of the pancreas, you will report C25.9 (Malignant neoplasm of pancreas, unspecified). You should not consider C25.8 (Malignant neoplasm of overlapping sites of pancreas) as this is reserved for two separate malignant neoplasms overlapping within the four main parts of the pancreas.

A malignant neoplasm of the biliary tract will also lead to an unspecified code. Within the Table of Neoplasms, you’ll find the keyword “bile or biliary (tract).” After concluding that no eligible indented sub-term exists underneath “bile or biliary (tract),” you’ll report C24.9 (Malignant neoplasm of biliary tract, unspecified) as your second and final diagnosis.

Don’t Discount the Power of the NCD

Diagnosis: Positron emission tomography (PET) scan performed for cancer surveillance. Patient is not actively being treated for lung malignancy.

When presented with a cancer surveillance diagnosis such as this, most of the confusion lies with whether a coder should report the neoplasm as current or historical. Fortunately, ICD-10-CM lays out clear guidelines — and they have to do with whether the patient is being actively treated:

“When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.”

You now know you’re definitively coding a “history of” diagnosis alongside a surveillance diagnosis. The next step in the equation is determining how to convert the “surveillance” portion of the diagnosis into the correct diagnosis code. On the surface, you might feel inclined to consider a screening code given the context of the PET scan. However, you should not consider Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs). That’s because, as Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City explains, there’s a more appropriate code to accurately assign codes for this condition as described.

“The correct code for this diagnostic encounter is Z08 [Encounter for follow-up examination after completed treatment for malignant neoplasm]. You may also report Z85.118 [Personal history of other malignant neoplasm of bronchus and lung] as a secondary diagnosis,” Bernard advises.

That’s not the end of your coding considerations, though. In fact, there’s an often-overlooked guideline you’ll need to take into account when coding for a service involving a PET scan. In November of 2018, The Centers for Medicare & Medicaid Services (CMS) issued a Change Request to NCD 220.6.17 Positron Emission Tomography (PET) for Oncologic Conditions. This Change Request includes numerous ICD-10-CM code additions and deletions to the NCD , but you’ll find the following note of most relevance to this example:

“CMS also instructs that whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D or R diagnosis codes.”

This means that within the context of this example, you should be reporting an active lung malignancy code alongside Z08 and Z85.118. Without any further specification as to the site of the lung malignancy, you will report C34.90 (Malignant neoplasm of unspecified part of unspecified bronchus or lung). Keep in mind Z08 should remain the principal diagnosis. Important: You should note, however, reporting a code from C, D or R diagnosis categories with Z85.- does not follow Official Coding Guidelines. However, CMS does require a diagnosis code from the list of covered C, D, or R code categories of ICD-10-CM whenever a personal history diagnosis code (Z85.-) is on a claim for PET scans.