Oncology & Hematology Coding Alert

Question: What first-listed diagnosis code should I use to go with CPT^® 36561 for chemo? Should I use Z45.2 or a cancer code?

AAPC Forum Participant

Answer: Coding in this situation is very much dependent on context. If you follow ICD-10-CM guideline IV.G, which tells you to “list first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided,” you can make a case for either of the codes you mention to accompany 36561 (Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older). Here’s why:

If the reason for the encounter is to insert the port-a-cath to infuse chemotherapy to treat the cancer at that encounter, you’d use Z51.11 (Encounter for antineoplastic chemotherapy) as primary and the cancer code secondary, as treating the cancer with a chemotherapy infusion is the reason for the encounter. However, payer coding policies may instruct differently, so you should reference your payer policy manual to be sure you are reporting these codes in the right sequence.

If the reason for the encounter is solely to insert the port-a-cath, and no treatment for the cancer occurred at the encounter, then you could make a case for Z45.2 (Encounter for adjustment and management of vascular access device). This time, ICD-10-CM guidelines for the aftercare Z category/code come into play. They reinforce guideline IV.G and tell you that this code “should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases.” But as treatment is not the purpose of the patient’s visit, you can list the Z code first for this encounter and add the cancer diagnosis code as secondary as supported by the documentation. See AHA Coding Clinic, Vol. 5, No. 3 (2018) for some additional context.

Z45.2 note: Even though the code descriptor only mentions “adjustment and management” of the device, you would still use this code for insertion, as the ICD-10-CM index entry for Fitting (and adjustment of) – portacath directs you to Z45.2.