Otolaryngology Coding Alert

If the ICD-9 neoplasm table has your head spinning, then help is here. Ask these five questions to simplify how you approach these tough neoplasm coding conundrums.

You'll understand all the relevant terminology necessary to understand and use the neoplasm table.

When the pathology comes back with a malignancy, you need to dig deeper. Under "malignant," the ICD-9 neoplasm table further breaks down the subcategories into three sections that includes primary.

Definition: A primary malignancy is one arising from the cells found where the ENT biopsied the neoplasm, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.

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).

You should use secondary 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. In other words, secondary malignancies are "metastatic cancer -- or where the cancer has spread to," says Julie Keene, CPC, CENTC,  otolaryngology coding and reimbursement specialist for UC Physicians Dept. of Otolaryngology: Head and Neck Surgery in Cincinnati.

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).

"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.

Translation: "The cancer is located in the cells and hasn't spread to surrounding tissues," Keene says.

You know that if pathology does not find evidence of cancer, you should not report a malignant ICD-9 code, but even benign neoplasms have subcategories.

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.

Key question: 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.

Question 5: Is Benign Neoplasm Unspecified?

You should use this category only when the ENT cannot determine the nature of the neoplasm. "If you don't have the path report, better go with 'unspecified' until the final report comes in," Keene says.

If the physician excises a tongue lesion but does not wait for the pathology report, for example, the unspecified code 239.0 (Neoplasms of unspecified nature; digestive system) is the only code you should use.

Caution: 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.