Oncology & Hematology Coding Alert

Clarify the limits of 'anemia in neoplastic disease,' or risk misrepresenting patient's condition.

Scenario: Suppose documentation shows a diagnosis of anemia. The cause of the anemia is documented as cancer (primary overlapping sites in the colon) and not treatment (chemotherapy). The patient presents solely for treatment of the anemia. You need to choose which diagnosis codes you apply to the case and what order they go in. Follow along to see where to turn for the information you need.

Pathology Interpretation Offers Best Neoplasm Code Support

First let's look at the appropriate neoplasm code. The documentation indicates overlapping cancerous neoplasms in the colon, so the appropriate code is 153.8(Malignant neoplasm of other specified sites of large intestine). A note with this code indicates it is appropriate for "Malignant neoplasm of contiguous or overlapping sites of colon whose point of origin cannot be determined."

Try this: You should look to the oncologist's interpretation of the pathology report to choose your neoplasm diagnosis code. "The pathology report is what most physicians use to establish the morphology and location(s) of a neoplastic process," explains Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill.

Ensure that the treating physician for whom you are coding has documented this interpretation. If no mention is made to connect the two documents, query the treating physician to determine the correct diagnosis to use.

In other words: The doctor uses the pathology report to establish whether the neoplasm is malignant. You should not choose a code for "malignant" without that confirmation.

Watch for: Sometimes critical lab values, such as for anemia, require immediate treatment. "The treatment is initiated based on the information that is available at the time, which may not include a pathology report," says Martin. In some cases, results of PET or CT scans may be used to establish a diagnosis "if a biopsy has not or cannot be done," she adds. In those cases, if there is no confirmation of a malignant neoplasm, remember that you should not choose a code specific to a malignant neoplasm.

"If a pathology report is not available to a treating physician, there should be documentation that may include what was utilized to establish the diagnosis, when the diagnosis was established, and who established the diagnosis," Martin notes.

First Find Cause, Then Choose Anemia Code

To select the sample scenario's anemia code, heed the documentation's statement that the cancer was the cause of the anemia. Once you pinpoint the cause, you'll know what elements to look for in the ICD-9 index. You'll find the entry under "Anemia; in (due to) (with); neoplastic disease," and it will point you to 285.22 (Anemia in neoplastic disease).

Checkpoint: Don't confuse 285.22 with the code for anemia caused by chemotherapy, which is 285.3 (Antineoplastic chemotherapy induced anemia), or the code for aplastic anemia due to chemotherapy, which is 284.89 (Other specified aplastic anemias, due to drugs). (Learn more about these codes in the next issue.)

Reality: Distinguishing the exact cause of anemia can be difficult when thepatient has a neoplastic disease as well as other chronic diseases, Martin says. "The cause of the anemia can also be a combination of conditions, such as anemia of chronic disease and anemia in neoplastic disease. If the anemia is present in a cancer patient prior to initiation of chemotherapy, the practitioner can at least establish that the chemotherapy was not the cause of the anemia." Alternatively, if anemia was not present prior to chemotherapy, then the physician may reasonably conclude that the chemotherapy was the cause, says Martin. The physician also should note whether the patient history or medication regime was contributory.

Bottom line: Documentation is key to your code choice. Establishing the cause of a patient's condition is important so the physician can correctly identify and treat the condition, says Martin. Establishing the cause also plays a role in supporting medical necessity for certain treatments under the patient's insurance plan.

"Clinical documentation improvement specialists have encouraged physicians to indicate how the diagnosis was established and what information was used to establish the diagnosis rather than simply stating a diagnosis," says Martin. Fortunately, this then makes it easier to code.

Guidelines Reveal Proper Code Order

Because the sample patient presents for treatment of the neoplasm-related anemia, your first-listed code should be the anemia code, 285.22.

You should list 153.8 as a secondary diagnosis, as the neoplasm is responsible for the anemia, says Martin.

ICD-9 official guidelines (section I.C.2.c.1) support this selection by stating, "When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code 285.22, Anemia in neoplastic disease) is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy." (Guidelines are available online at www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.)

Key distinction: If the patient instead presents for treatment of the malignancy, 285.22 is not first-listed. But you may report 285.22 as a secondary code in that situation, as the guidelines indicate (section I.C.2.c.1). Additionally, if documentation shows both anemia in neoplastic disease (285.22) and chemotherapy-induced anemia (285.3), you may assign both codes, guidelines state (section I.C.2.c.1).

Part 2: Check back next month for tips on keeping track of important coding rules and a comparison of ICD-9 and ICD-10 anemia guidelines.