Oncology & Hematology Coding Alert

In tip 3, find out why 233.2 claims demand a second look

Uterine cancer is the most common type of gynecologic cancer, so one bad ICD-9 habit could sink a large number of your claims. There's no better time to hone your diagnosis coding know-how than September -- Gynecologic Cancer Awareness Month. These five tips get you on your way.

1. Pay Attention to Digits for Primary Neoplasm

About 90 percent of uterine cancer begins in the lining, says coding consultant Melanie Witt, RN, CPC-OGS, MA, in her Coding Institute audioconference, -Tackle Tough Gyn Oncology Coding.-

This lining is also called the endometrium, and a primary neoplasm of the endometrium merits 182.0 (Malignant neoplasm of body of uterus; corpus uteri, except isthmus), according to the ICD-9 manual's neoplasm table.

You should always check the index entry in the ICD-9 tabular list to be sure you report the most accurate code. Flip to 182 (Malignant neoplasm of body of uterus) in the tabular list, and you see an instruction to --4th- -- meaning that you should report a code with a fourth digit instead of reporting the three-digit 182. Your options are 182.0, 182.1 (- isthmus), and 182.8 (... other specified sites of body of uterus).

The tabular list verifies that 182.0 is the appropriate code: A note with 182.0 says the code describes primary malignant neoplasms of the endometrium, as well as the cornu, fundus, and myometrium. This list is made of -inclusion terms- according to the official ICD-9 guidelines (www.cdc.gov/nchs/data/icd9/icdguide.pdf). Inclusion terms may be synonyms for the code title or conditions assigned to an -other specified- code.

Tip: Inclusion terms aren't exhaustive, so if a term in the index directs you to a code, but you don't see the term in the inclusion list, the code may still be correct.

Heads up: The ICD-9 manual offers different codes for various parts of the uterus, so take time to check the code for the specific neoplasm site. For example, you should report 180.x (Malignant neoplasm of cervix uteri) for a primary malignant neoplasm of the cervix.

When the documentation isn't clear about where the neoplasm is located in the uterus, you should look beyond the 182 codes.

In this case, report 179 (Malignant neoplasm of uterus, part unspecified), Witt says.

2. Seek Out the Proper Secondary Code

In some cases, the uterine neoplasm is the result of a primary neoplasm in another part of the body metastasizing. In this case you should report a secondary neoplasm code.

For uterine cancer, the secondary neoplasm code is 198.82 (Secondary malignant neoplasm of other specified sites; genital organs), Witt says.

Tip: Next to code 198.8 (... other specified sites) the ICD-9 manual includes a note to -5th.- Similar to the 4th instruction, 5th requires you to choose a code that has an additional digit. As a result, you should never report 198.8. You should always choose a more definitive code -- 198.81 (- breast), 198.82, or 198.89 (- other).

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Watch for: Under diagnosis code 180, you-ll see the notations -Includes: invasive malignancy [carcinoma]- and -Excludes: carcinoma in situ (233.1).- ICD-9 guidelines instruct that an -Includes- note further defines or gives examples of the category content. An -Excludes- note lists terms you should code elsewhere. In this case, if your patient has a carcinoma in situ, you should report 233.1 (Carcinoma in situ of breast and genitourinary system; cervix uteri) instead of reporting a 180.x code.

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3. Don't Confuse 233.2 and 621.3x

Although the ICD-9 manual shows 233.2 (Carcinoma in situ of breast and genitourinary system; other and unspecified parts of uterus) as the code for a uterine carcinoma in situ, you-ll rarely use this code, Witt says. Reason: Endometrial hyperplasia is often the closest you-ll come to an endometrial carcinoma in situ, and it has its own code, she says.

If the true diagnosis is indeed endometrial hyperplasia, choose the appropriate code from the 621.3x range (Endometrial hyperplasia). Note that again you-ll see a -5th instruction, meaning you must choose a code with one more digit than 621.3.

4. Base -Uncertain- Code on Path Report

Code 236.0 (Neoplasm of uncertain behavior of genitourinary organs; uterus) describes a uterine neoplasm of uncertain behavior, and 239.5 (Neoplasms of unspecified nature; other genitourinary organs) describes a neoplasm of unspecified nature, Witt says.
 Important: You should base your use of these codes on the pathology report. You should NOT use an uncertain or unspecified code when you -- the coder -- are uncertain, Witt says.

In other words, don't simply flip to the Neoplasm Table and select a code from either of these columns.    

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Tip: The majority of uterine cancers are adenocarcinomas. The ICD-9 index entry for adenocarcinoma instructs you to -see also Neoplasm, by site, malignant.- Translation: For a uterine adenocarcinoma, turn to the ICD-9 neoplasm table and search for the proper code under the uterus entry (malignancy column), based on the neoplasm's location (such as the endometrium). Then verify your code choice in the tabular list.

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Instead, use the ICD-9 alphabetic index to look up the terms the physician uses in his diagnosis. The index will direct you to the right place. Example: The physician documents a uterine tumor. You look up -tumor- in the alphabetic index, which states to -see also, Neoplasm, by site, unspecified nature.- You then go the Neoplasm Table and look up uterus in the unspecified nature column and find code 239.5.

Helpful: If the path report comes back uncertain, fight the temptation to create a more definitive diagnosis.

You should never choose your code based on the ordering physician's -suspected- or -rule-out- diagnosis, says MaryAnn Luick, CPC, CCP, with the UPMC Cancer Pavilion in Pittsburgh.

5. Check Whether Fibroid Code Is More Appropriate

When it comes to benign neoplasms and masses, the terms your oncologist documents can clue you in to which diagnosis code best describes the patient's condition.

Benign: Don't automatically report every benign uterine neoplasm with a 219.x code (Other benign neoplasm of uterus).
Remember that tumors are classified by what they are, Witt says. Example: You should report a uterine fibroid (benign tumor) with a 218.x code (Uterine leiomyoma) and endometriosis with 617.0 (Endometriosis of uterus), Witt says.

Mass: Don't make the mistake of assuming a mass is the same as a neoplasm, Luick says. The ICD-9 index instructs you to look to 625.8 (Other specified symptoms associated with female genital organs) for uterine masses.