Oncology & Hematology Coding Alert

Question: Our oncologist met with a patient to discuss the best way to manage her brain lesions. The lesions had not been biopsied, only imaged, and the oncologist told her that any treatment directed to the brain would be under presumption of association with her prior ovarian cancer.

The oncologist wants to code it as C79.31, but if we follow coding guidelines, we technically should not be coding it this way as there is no confirmed pathology. Is our oncologist right, and if not, how should we code this?

AAPC Forum Participant

Answer: If the physician had stated this is a secondary malignancy to the ovarian cancer, then they have ruled the condition as such. However, given the details you have provided, you cannot code C79.31 (Secondary malignant neoplasm of brain) for this encounter. The medical record lacks information that the lesions have been biopsied or that the physician has diagnosed the condition based on their medical judgement. You should query the physician if the documentation isn’t clear.

If there is no conclusive evidence of cancer in the present documentation, the oncologist did not provide a definitive diagnosis. Additionally, the provider’s documentation of “prior ovarian cancer” indicates a prior history, and there is only a presumption that the metastatic cancer is related to the prior ovarian cancer.

In other words, the information indicates a “presumptive” condition, and professional fee and outpatient services do not allow coding for rule out or suspected conditions. Therefore, due to the consultative nature of the encounter, perhaps the best way to code the diagnosis would be R90.0 (Intracranial space-occupying lesion found on diagnostic imaging of central nervous system) along with Z85.43 (Personal history of malignant neoplasm of ovary), again assuming the ovarian cancer is not currently active. Then, when the lesions are biopsied or the nature of the lesions confirmed, you may be able to use a more definitive diagnosis code such as C79.31.