Oncology & Hematology Coding Alert

 Don't count on the ICD-9 neoplasm table to hold all the answers

If you code for an oncology practice, you're coding neoplasms - a challenge that demands in-depth knowledge for accurate coding. Follow our quick guide to help keep denials at bay.

1. Bide Your Time for the Path Report

"Without the pathology report, you're just guessing what kind of neoplasm you're dealing with," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa. Even if the ordering physician has a strong suspicion that the growth is cancerous, for instance, the diagnosis is still unconfirmed until you get the pathology results.
 
Never code based on a "suspected" or "rule-out" diagnosis that the ordering physician may submit, agrees MaryAnn Luick, CPC, CCP, with the UPMC Cancer Pavilion in Pittsburgh. And remember, a mass is not the same as a neoplasm, she says.
 
Bottom line: Choosing a diagnosis is hard enough, so be sure you have all the relevant information before you proceed.

2. Pinpoint the Type of Neoplasm

With the pathology report in hand, first determine if the neoplasm is benign or malignant. If it's malignant, you'll have to identify the type: primary, secondary, or     in situ (see "Glide Through Neoplasm Coding With This At-a-Glance Glossary" on page 60 for more on the different types of neoplasms). 
 
The pathology report usually identifies the type of neoplasm. Snag: Reading path reports can be very tricky, says Beth Potratz, CPC-A, with The Cancer Treatment Center in Swansea, Ill. Clarify any questions you have about wording before you move on to the next step.

3. Check With ICD-9 Volume 2

Next, you should go to the alphabetic index (volume 2) of the ICD-9 manual and look up the main term that describes the neoplasm type, such as melanoma, lymphoma, or adenocarcinoma. 
  
Don't skip to the neoplasm table: Although the alphabetic index will often direct you to the neoplasm table, checking the index is not a wasted step. Some conditions are only listed in the index, and sometimes using the index simply saves time.
  
Example: If you look up "melanoma (malignant), lip" in the alphabetical index, you will find 172.0 (Malignant melanoma of skin; lip). But if you had started with the neoplasm table, you might have looked up "lip" and chosen 140.9 (Malignant neoplasm of lip, unspecified, vermilion border). Or you might have looked up "skin, lip" and chosen 173.0 (Other malignant neoplasm of skin; skin of lip) in error.

4. Advance to the Neoplasm Table

If the alphabetical index doesn't provide the information you need, you should next consult the neoplasm table.
  
Example: A patient may exhibit malignant mesothelioma. If you find this term in the ICD-9 index,
the entry will direct you to the neoplasm table, stating, "see also Neoplasm, by site, malignant."
  
If you find the entry for "breast" in the neoplasm table, you will notice that the codes are further differentiated according to the exact area of the breast and the type of malignancy.
  
If, for example, the surgeon removed the specimen from the lower-inner quadrant and the pathology report verifies primary malignancy, you should choose 174.3 (Malignant neoplasm of female breast; lower-inner quadrant).
 
"Skin" lesions require special consideration: For neoplasms that occur on or near the skin of an anatomic site, you should assign a diagnosis for skin - not for the body area in question. For instance, if the physician removes a lesion from the skin of a woman's breast that pathology determines is benign, you should report 216.5 (Benign neoplasm of skin; skin of trunk, except scrotum).

5.  Always Check the Tabular List

Once you've found a code from the alphabetic index or neoplasm table, you always need to look it up in ICD-9 Volume 1.
  
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 pathology report, which helps you confirm an accurate diagnosis or avoid a wrong one.
  
Pitfall: Pinpointing the correct tumor location, especially for metastatic sites, is a challenge, Potratz says. Example: A report that describes a primary tumor in the small intestine is not nearly specific enough. You've got different codes for the duodenum, ileum, jejunum, AND contiguous sites, so scour the report to choose the most specific code.
 
What to do: Specify the anatomical location of the metastasis, Luick says. And try to avoid using ".9," which typically identifies an unspecified location, she adds. Payers want you to specify if leukemia or multiple myeloma is in remission and specify the cell type and anatomical location of all lymphomas, Luick says. Example: Report acute lymphoid leukemia in remission with 204.01

6. Code Co-Existing Conditions

If the patient has other conditions pertinent to the treatment, be sure to code these too, Luick says. You may need to report anemia or neutropenia.
 
For anemia (often a 28x.x code), specify the cause and the type, such as iron deficiency, pernicious or aplastic. Example: If your report says anemia in neoplastic disease, report 285.22.