Oncology & Hematology Coding Alert

Question: What is the appropriate diagnosis to use when a provider performs a biopsy of the area lymph nodes to check for metastatic cancer and the biopsy returns as negative? I have some colleagues that say you should use D36.0 rather than the primary cancer, but I was trained that we use the cancer code as the lymph node is not actually a neoplasm.

AAPC Forum Participant

Answer: Using D36.0 (Benign neoplasm of lymph nodes) would only be correct if there had been a neoplasm on the nodes, and then the pathology report came back with a diagnosis of a neoplasm in the lymph nodes that was now benign.

But that is not what happened in this case. As the report came back as negative, the code you should report will be based upon the provider’s supporting documentation/rationale for performing the biopsy. For example, if the documentation indicated the lymph node was biopsied to rule out any involvement of the lymph node due to the primary cancer, you would use the appropriate code for the primary cancer as the primary diagnosis. If the reason the lymph node was biopsied was due to a sign or symptom affecting the lymph node, then the sign or symptom would be the primary diagnosis with the primary cancer being secondary, since at the time of biopsy the result was unknown, and the provider documented the sign or symptom as the rational for the procedure.