Oncology & Hematology Coding Alert

Question: If a patient has cancer, and the provider states the patient also has lymphadenopathy (from reviewing the imaging), would it be appropriate to code the lymphadenopathy as lymph mets?

AAPC Forum Participant

Answer: Unless the clinician has clearly documented it in the notes, or there is a biopsy proving that the cancer in the lymph nodes has metastasized, you should not code the lymphadenopathy as lymph mets.

Instead, assuming you are coding in an outpatient setting and not in a short-term, acute care, long-term care, or psychiatric hospital setting, you should follow ICD-10-CM guideline IV.H, which tells you to “code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

This means coding the lymphadenopathy using the appropriate signs and symptoms code: R59.1 (Generalized enlarged lymph nodes).