Oncology & Hematology Coding Alert

Take this advice, take your breast cancer coding to the next level.

In the first article of this two-part series, Halee Garner, CPC, CPMA, CHONC, CCA, CPhT, AAPC Approved Instructor, quality assurance coordinator for Florida Cancer Specialists & Research Institute in Fort Myers, Florida, offered her advice on how to document breast cancer diagnoses and mastectomies.

This month, in Part 2, we’ll look at more of advice taken from Garner’s HEALTHCON Regional 2024 presentation “Breast Cancer Coding” on how to code for breast cancer symptoms prior to diagnosis, how to document common intravenous (IV) breast cancer drug treatments, and how to document breast reconstruction.

Know How to Code Common Breast Conditions Before a Cancer Dx

Before the provider can assign a definitive cancer diagnosis, a patient may visit your provider with possible signs or symptoms. Garner suggested becoming familiar with those symptoms by consulting the Centers for Disease Control and Prevention’s (CDC’s) list of breast cancer symptoms. They include:

• New lump in the breast or underarm (armpit)
• Thickening or swelling of part of the breast
• Irritation or dimpling of breast skin
• Redness or flaky skin in the nipple area or the breast
• Pulling in of the nipple or pain in the nipple area
• Nipple discharge other than breast milk, including blood
• Any change in the size or the shape of the breast
• Pain in any area of the breast

This, in turn, means becoming familiar with such codes as the N63.- (Unspecified lump in breast) codes, N64.52 (Nipple discharge) and N64.59 (Other signs and symptoms in breast), which will come into play in patient visits prior to the provider assigning a specific code for breast cancer once the patient has been formally diagnosed with the condition.

Connect With These Common Breast Cancer Drugs

Once the provider has arrived at a definitive diagnosis and the patient undergoes treatment for breast cancer, it’s also a good idea to familiarize yourself with the drugs most commonly used for breast cancer treatment. Many are from the taxane class, according to Garner, which include the following:

• J9171 (Injection, docetaxel, 1mg)
• J9264 (Injection, paclitaxel protein-bound particles, 1 mg)
• J9267 (Injection, paclitaxel, 1 mg)

Garner noted these should all be documented in milligram, not milliliter, units.

Other common IV chemotherapy drugs include J9201 (Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg), which is commonly used in conjunction with J9267, and J9190 (Injection, fluorouracil, 500 mg), which typically needs a prolonged time IV administration code.

On the immunotherapy side, the most common drug is J9271 (Injection, pembrolizumab, 1 mg). This drug is typically given with other chemotherapy drugs and uses chemotherapy administration codes. But as J9271 is an immunotherapy drug, you should use Z51.12 (Encounter for antineoplastic immunotherapy) and not Z51.11 (Encounter for antineoplastic chemotherapy) to document the encounter according to Garner.

Add This Chemo Administration Knowledge to Your Coding Arsenal

In her review of the IV chemotherapy administration codes, Garner noted the subtle but important language of the descriptors for 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) and 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic). You would use 96401 for administering non-hormonal drugs, such as one of the taxane drugs mentioned earlier, while 96402 would be more appropriate to code for administering a hormonal drug such as J9395 (Injection, fulvestrant, 25 mg).

Importantly, too, Garner noted that 96401 and 96402 are both for anti-neoplastic drugs. So, “if a patient comes in for a methotrexate shot for their RA [rheumatoid arthritis], that’s not anti-neoplastic, so you have to resort back to your regular IV or injection code for that,” she cautioned. In such cases, that would mean using a code such as 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).

Remember These Rules for Breast Reconstruction

Patients who have to go through mastectomies often undergo breast reconstruction. Here, your code choices for breast implant surgery are fairly straightforward, but Garner offered a few tips to make sure you get your coding correct.

She noted, for example, that 19340 (Insertion of breast implant on same day of mastectomy (ie, immediate)) must be on the same claim if performed on the same day by the same physician. Otherwise, you’ll have to use 19342 (Insertion or replacement of breast implant on separate day from mastectomy).

Additionally, Garner offered the reminder that if the surgeon has used a tissue expander to enable the implant to be put into place, you’ll code 11970 (Replacement of tissue expander with permanent implant) in addition to one of the implant codes.

And add this breast reconstruction anesthesia code: Garner noted that anesthesia for breast reconstruction will be coded to 00402 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast [e.g., reduction or augmentation mammoplasty, muscle flaps]). But it is important to remember the code will need a physical status modifier, such as P1: A normal healthy patient, to indicate the patient’s health at the time of the procedure. So, surgery for a normal, healthy patient receiving anesthesia for a breast implant occurring on a different day from the patient’s mastectomy would be documented with the following: 19342, 00402-P1.

Garner recommended consulting Novitas Solutions comprehensive list of anesthesia modifiers for further information. The list also includes modifiers used to indicate who performed the anesthesia services.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC