Pathology/Lab Coding Alert

 Know the ICD-9 table and terminology to get the code right

When the pathologist renders a narrative cancer diagnosis based on the tissue exam, you may have to assign the ICD-9 code. Nailing down the neoplasm diagnosis is critical for reimbursement. Follow these five  expert tips to produce correctly coded claims every time.

Tip 1: Don't Make a Move Without the Path Report

Don't even try to choose a neoplasm diagnosis until you've received the results of the pathology study. Don't code based on a "suspected" or "rule-out" diagnosis that the ordering physician may submit.
 
"Without the pathology report, you're just guessing what kind of neoplasm you're dealing with," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Landsdale, Pa. Even if the ordering physician has a strong suspicion that the growth is cancerous, for instance, the diagnosis is still unconfirmed until you get the pathology results.
 
Entering the wrong diagnosis can have serious effects. You don't want to label a patient as having cancer if the diagnosis isn't certain, says Darren Carter, MD, president of Provistas Inc. in New York City. A cancer diagnosis is a red flag for insurers that could make it more difficult for the patient to gain medical coverage.
 
However, failure to indicate a malignant lesion when present will limit the coding for the current procedure and can also limit the treatment options that the insurer may accept at a later date. 
 
Bottom line: Choosing a diagnosis is hard enough, so be sure you have all the relevant information before you proceed.

Tip 2: Identify the Type of Neoplasm

With the pathology report in hand, first determine if the neoplasm is benign or malignant. If it's malignant, you'll have to identify the type: primary, secondary or     in situ (see "Decipher Malignant, In Situ and Uncertain" on page 47 for more on the different types of neoplasms). 
 
"A pathology report usually clearly identifies the type of neoplasm," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "Using this information, you're ready to go to ICD-9 and find the diagnosis code that fits."

Tip 3: Consult ICD-9 Volume 2

Next, you should go to the alphabetic index (volume 2) of the ICD-9 manual and look up the main term that describes the neoplasm type, such as melanoma or lymphoma or adenocarcinoma.
 
Don't skip to the neoplasm table: Although the alphabetic index will often direct you to the neoplasm table, checking the index is not a wasted step.
 
"You won't find all the codes you need in the neoplasm table," Jandroep says. "Certain types of conditions are only listed in the index, and in other cases, using the index will save time and reduce confusion."
 
Example: If you look up "melanoma (malignant), lip" in the alphabetical index, you will find code 172.0 (Malignant melanoma of skin; lip). But if you had started with the neoplasm table, you might have looked up "lip" and chosen 140.9 (Malignant neoplasm of lip, unspecified, vermilion border). Or you might have looked up "skin, lip" and chosen code 173.0 (Other malignant neoplasm of skin; skin of lip).

Tip 4: Head for the Neoplasm Table

If the alphabetical index doesn't provide the information you need, you should next consult the neoplasm table.
 
For example: A patient may exhibit malignant mesothelioma. If you find this term in the ICD-9 index, the entry will direct you to the neoplasm table, stating, "see also Neoplasm, by site, malignant."
 
If you find the entry for "breast" in the neoplasm table, you will notice that the codes are further differentiated according to the exact area of the breast and the type of malignancy.
 
If, for example, the surgeon removed the specimen from the lower-inner quadrant and the pathology report verifies primary malignancy, you should choose 174.3 (Malignant neoplasm of female breast; lower-inner quadrant).
 
"Skin" lesions require special consideration: For neoplasms that occur on or near the skin of an anatomic site, you should assign a diagnosis for skin - not for the body area in question. For instance, if the physician removes a lesion from the skin of a woman's breast that pathology determines is benign, you should report 216.5 (Benign neoplasm of skin; skin of trunk, except scrotum).

Tip 5: Always Check the Tabular List

Once you've found a code from the alphabetic index or neoplasm table, you need to look it up in ICD-9 Volume 1.
 
Best advice: In all cases, before assigning a final code, verify the diagnosis you have selected in the tabular index, Jandroep says.
 
The tabular list provides additional information that you won't find in the alphabetic listing or neoplasm table. For instance, a specific category might show a list of terms that the code "includes" or "excludes." Here you may find a term that you see in the pathology report, which helps you confirm an accurate diagnosis or avoid a wrong one.
 
Example: If the pathology report indicates malignant melanoma of the lip skin, but you looked up "malignant neoplasm, skin, lip" in the neoplasm table, double-checking 173 in the tabular list would save you from a coding error. You'll find malignant melanoma of skin in the "excludes" list under category 173, along with direction to see codes 172.0-172.9.