Pathology/Lab Coding Alert

Use this primer to zero in on neoplasm type 

If you wonder what "behavior" and other terms have to do with cancer diagnoses, you're not alone. Look at our experts' explanation of the basic organization and language of neoplasms, and you'll never again doubt your cancer coding choices.

Malignant and Benign Define Main Categories

When looking at the neoplasm table in ICD-9 Volume 2, you will notice two main categories of neoplasm: malignant and benign. Malignant cancers are locally invasive and can spread to distant sites (metastasis), and the table further subdivides malignant neoplasm into three subcategories as follows:
 
Primary. A primary malignancy is one arising from the cells found where the physician excised or biopsied the neoplasm, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM Program Coordinator at Clarkson College in Omaha, Neb. Primary means the original cancer site.
 
Secondary. You should use these codes when the neoplasm is the result of metastasis and forms a new focus of malignancy elsewhere, such as the lymph nodes, liver, lungs or brain, or when the primary cancer has invaded adjacent structures. You should always code both the secondary and primary malignancy codes on the claim form.
 
In situ. In situ describes malignancies confined to the site of origin that do not metastasize to other tissues, although the growths can be large enough to cause major problems, Bucknam says. In some cases, however - such as those involving the breast (233.0), bladder (233.7) and cervix (233.1), for instance - there is no guarantee that removal of the mass will totally eradicate the cancer.

No Cancer = No Malignancy
 
If the pathologist does not find evidence of cancer, you should not report a malignant ICD-9 code. Instead, based on the description in the pathology report and the ICD-9 alphabetic index and neoplasm table, choose from the following three categories:
 
Benign. Benign neoplasms are growths that are cancer-free. For example, for a fibroadenoma of the breast, which does not spread, report a benign neoplasm (217). Benign neoplasms may return after removal, but they are non-invasive, Bucknam explains. Even if the pathology report does not state "benign," the ICD-9 alphabetic index entry for fibroadenoma identifies the growth as benign.
 
Uncertain behavior. If the pathology report returns with indications of atypia or dysplasia, the neoplasm may be "in transition" from benign to malignant. If the process continues and the mass is left untreated, the neoplasm could eventually become malignant. Again, the pathology report and ICD-9 index will indicate when you should use codes from the "uncertain behavior" column in the neoplasm table.
 
Unspecified. You should use this category only when the physician cannot determine the nature of the neoplasm. If the pathology report does not confirm a specific type of neoplasm that you can code more specifically, you should report the unspecified codes.
 
Do not confuse "uncertain" with "unspecified." "A pathologist makes the 'uncertain' determination based on analysis," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Landsdale, Pa. If the pathologist labels the neoplasm uncertain, you shouldn't use an unspecified diagnosis, because "unspecified" implies that the physician's documentation didn't indicate the lesion's type.