Oncology & Hematology Coding Alert

Question: One of our oncologists is capturing general complaints, like malaise and fatigue, for patients with cancer, but I’m confused about how to report this. What should I do?

Iowa Subscriber

Answer: If the malaise and fatigue are documented as “attributed” to, or a sign/symptom of, the cancer, then you should code these. ICD-10-CM Official Guidelines for Coding and Reporting FY 2019 Section I.B.5. Conditions that are an integral part of a disease process: “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.”

You won’t find any clear differentiation of the terms “malaise” and “fatigue,” and the two may be used interchangeably. Fatigue is usually described as an exertion or exhaustion. Malaise on the other hand is an unpleasant tired feeling or discomfort usually attributed to illness.

You have ICD-10-CM code R53.81 (Other malaise) for malaise and R53.83 (Other fatigue) for fatigue. Malaise and fatigue are underlying signs and symptoms of cancer. Also note there is an ICD-10-CM code for Neoplastic (malignant) related fatigue (R53.0) which should be used instead of “other fatigue.” There is not an ICD-10-CM code to assign for neoplastic related malaise. See also sections I.C.18.a-c for further information and clarification in determining the right code(s) to assign.

How to choose the correct code? With no clear distinction between the terms “malaise” and “fatigue,” you choose the code depending upon what your physician documents. We also have to ask ourselves, “is the malaise and fatigue related to chemotherapy or other therapies?” The reason? You may need to consider a completely different reportable diagnosis (Adverse Effect) of chemotherapy and/or the treatment related to their disease.

Key: It is important in the overall picture of the patient’s state of health and sometimes as important as the diagnosis codes for the cancer, associated co-morbidities and treatment(s).