Oncology & Hematology Coding Alert

Pay attention to ‘other’ versus ‘unspecified’ distinction.

When your physician makes a diagnosis of benign tumor in the patient’s mouth, you check the clinical note to confirm the specific structure within the mouth was involved. The documentation should specify the location of the tumor in the mouth, however, you may not always find the information needed to assign the most specific ICD-10-CM code. In this situation, you can choose from two codes in ICD-10-CM.

Make note of specific codes: You now have two D codes with fifth characters that identify unspecified and other parts of mouth from where the tumor grows. These news codes are:

• D10.30 — Benign neoplasm of unspecified part of mouth
• D10.39 — Benign neoplasm of other parts of mouth.

You submit code D10.39 for benign neoplasms located as part of the mouth when the information in the medical record provides detail of the location where a specific code does not exist. For benign neoplasms in the oral cavity where no additional information about the location are provided in the documentation you would choose code D10.39.

Looking back into ICD-9-CM: When you still coded by ICD-9-CM, you would report 210.4 (Benign neoplasm of other and unspecified parts of mouth) for patients diagnosed with tumors of the mouth. This code included all of the structures now covered in D10.30 and D10.39.

Documentation: Take note of your provider’s documentation of symptoms, which may depend on the cell type of origin, size and location of the growth, and the organ system involved. The patient may report noticing a lump or skin change. If the tumor disturbs the nerves, it can cause pain or disorders (such as dizziness, weakness, or headaches). Make sure the physician confirms in her notes that her diagnosis is benign.

Coder tips: After your health care provider has performed a physical exam of the mouth, a biopsy using CPT® codes such as 40808 (Biopsy, vestibule of mouth), 41108 (Biopsy of floor of mouth), 42800 (Biopsy; oropharynx), 42100 (Biopsy of palate, uvula), or 40490 (Biopsy of lip) may be performed to determine the specific nature of the growth. Depending on the location and size of the tumor, surgery may be recommended, which often completely removes the tumor.

About the diagnosis: Many different cell types make up different structures of the mouth. Cancer occurs when normal cells undergo a transformation whereby they grow and multiply without normal controls. As the cells multiply, they form small abnormalities called lesions. Eventually, they form a mass called a tumor. If the tumor is benign, it is not cancerous. The general rule for benign tumors is that although they may grow and penetrate below the surface layer of tissue, they do not spread to other parts of the body.