Otolaryngology Coding Alert

Learn the differences between primary, secondary and in situ

You-ve used our article and chart to pinpoint the site of the cancer, but the ICD-9 neoplasm table lists so many types of cancer--primary, in situ, etc.--that your head is spinning. Now you can simplify how you approach these tough neoplasm coding conundrums with this quick review of the relevant terminology you-ll face when reading the neoplasm table.

Malignant and Benign Define Main Categories

When looking at the ICD-9 neoplasm table, you will find two main categories of neoplasms: malignant and benign. Under -malignant,- the manual further breaks down the subcategories into three sections:

Subcategory 1: Primary. A primary malignancy is one arising from the cells found where the neoplasm was biopsied, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

Example: A biopsy shows that a male patient has a neoplasm of the tongue. It is malignant and comprises cancer cells from the area of excision (as opposed to cancer cells that originated elsewhere--such as the lip--and spread to the tongue). Code a primary malignancy using 141.x (Malignant neoplasm of tongue).

Subcategory 2: Secondary. You should use these codes when the neoplasm is the result of metastasis from another organ or focus of malignancy elsewhere, such as the lymph nodes, throat or brain, or when the primary malignancy invades the organ in question from an adjacent structure or organ.

Example: The otolaryngologist removes a neoplasm from the tongue, and the pathology report indicates that the cancer is a secondary malignancy with the stomach as the origin. You should report a secondary neoplasm code: 198.89 (Secondary malignant neoplasm of other specified sites; other).

Subcategory 3: In situ. -In situ- describes malignancies confined to the site of origin without invasion of neighboring tissues, although they can grow large enough to cause major problems, Bucknam says. In some cases, however, there is no guarantee that removal of the mass will totally eradicate the cancer. In other words, -in situ- describes encapsulated malignancies, confined to the site of origin.

Benign Neoplasms Are Noncancerous

If pathology does not find evidence of cancer, you should not report a malignant ICD-9 code. Instead, choose from the following three categories:

Benign: Benign neoplasms are cancer-free.

Uncertain behavior: If the pathology report returns with indications of atypia or dysplasia, the neoplasm is in transition from benign to malignant. If the process continues and the mass is left untreated, the neoplasm could eventually become malignant.

Remember that only a pathologist can definitively indicate a diagnosis of uncertain behavior. If an otolaryngologist or other nonpathologist is uncertain about a diagnosis, it means you should report the -unspecified- code (below), not the uncertain behavior code.

Differentiate Unspecified From Uncertain

Unspecified: You should only use this category when the ENT cannot determine the nature of the neoplasm. If the physician excises a tongue lesion but does not wait for the pathology report, for example, the unspecified ICD-9 code 239.0 (Neoplasms of unspecified nature; digestive system) is the only code you should use.

Remember: Although your head and neck surgeon can probably say with 99.9 percent accuracy that he believes a lesion is malignant based on his visualization of the lesion, you can never code a malignant cancer diagnosis unless the pathology report comes back with a carcinoma diagnosis.