Oncology & Hematology Coding Alert

Mastering uncertain vs. unspecified is an oncology coding essential.

Unless you've got the terms "uncertain" and "unspecified" down pat, you're setting yourself up for miscoded claims. Take a look at our experts' explanations and examples to make sure you know the difference.

Know How the Neoplasm Table Can Help

To understand the uncertain/unspecified distinction, you need to comprehend the overall neoplasm diagnostic classification scheme. The ICD-9 neoplasm table distinguishes cancers as malignant, benign, uncertain, or unspecified. Starting with the malignant/benign difference will help you understand the "uncertain" classification.

Malignant: A malignant neoplasm is cancerous and may be invasive or noninvasive (also called in situ), explains R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

For invasive cancers, you also have to choose between primary and secondary. "Primary" means that the cancer arises from surrounding cells. "Secondary" means that the cancer metastasized (spread) from a primary malignancy located elsewhere in the body.

For each anatomic location, ICD-9 distinguishes the cancer types with different codes. For example, for the neck of the bladder you would choose from the following codes:

Benign: Benign neoplasms are cancer-free. For example, for a fibroadenoma of the breast, you should report 217 (Benign neoplasm of breast). Oncology coders are of course more likely to encounter malignant neoplasms in the documentation, but physicians may order radiation or therapeutic infusion for some benign tumors, as well.

Tip: Don't report every benign neoplasm using the general benign neoplasm code for that body site. "Choose the code based on the specific description from the pathology report," says Melanie Witt, RN, CPC, COBGC, MA, a coding expert based in Guadalupita, N.M. For example, for a uterine fibroid, instead of 219.x (Other benign neoplasm of uterus), the more appropriate code may be 218.x (Uterine leiomyoma). Use both the ICD-9 index and tabular list to be sure you've chosen the most appropriate code based on the documentation.

Make Certain It's Uncertain

Benign and malignant aren't the only neoplasm classifications available. "Sometimes the pathologist identifies a neoplasm that is currently benign but exhibits characteristics indicating that it might become malignant," Stainton says. Because the tumor has an "unpredictable" behavior, it fits a category called "neoplasm of uncertain behavior." ICD-9 describes these tumors as "histomorphologically well-defined neoplasms, the subsequent behavior of which cannot be predicted from the present appearance."

Uncertain is not unspecified: "Neoplasms of uncertain behavior have very specific histology that the pathologist describes," Stainton says. They are not unspecified. If the pathology report indicates atypia or dysplasia, the neoplasm is "in transition" from benign to malignant and is therefore "uncertain." If the process continues and the mass goes untreated, the neoplasm could eventually become malignant.

Bottom line: A pathologist makes the "uncertain" determination based on analysis.

You'll find the codes for uncertain behavior in the following ICD-9 categories:

Reserve Unspecified for Minimal Information

When the pathology report and medical record don't confirm a specific type of neoplasm -- benign, malignant, or uncertain -- you should report an unspecified code.

For instance: You'd use an unspecified code if you're billing before you have the biopsy results or when the pathology report and oncologist's documentation don't contain enough information to select a more specific code. "Unspecified" indicates that the pathologist did not reach a specific diagnosis, possibly due to an inadequate specimen.

ICD-9 provides "unspecified" codes in category 239 (Neoplasms of unspecified nature).

Coverage alert: Many payers have policies that provide lists of covered diagnoses. Many of these medical necessity policies don't include codes from category 239. But remember that you should never report a diagnosis code simply because it's one that will bring payment. The documentation must support your coding choice. Instead, when appropriate, your practice should present the patient with a waiver of liability, or Advance Beneficiary Notice (ABN) for Medicare patients, to make the patient aware that the insurance company may not pay for this procedure if it is outside the medical coverage policy.

Follow These Steps to Pick the Right Dx

"You should not use an uncertain or unspecified code when you -- the coder -- are uncertain," Witt says. "Don't simply flip to the neoplasm table and select a code from either of these columns."

Instead: Look very carefully at the available documentation. Then, you should use the alphabetic index to look up the name of the tumor or available diagnostic information. The index directs you to the appropriate code or to the neoplasm table. Before assigning a final code, verify the diagnosis you have selected in the tabular list. The tabular list provides additional information that you won't find in the alphabetic listing or neoplasm table. For instance, a specific category might show a list of terms that the code "includes" or "excludes." Here you may find a term that you see in the oncologist's interpretation of the pathology report, which helps you confirm an accurate diagnosis or avoid a wrong one.

Tip: "Includes" lists aren't exhaustive, so if a term in the index directs you to a code, that can be the correct code even if the term is not in the inclusion list.