Urology Coding Alert

Look deeper than ‘malignant’ in the documentation.

You have been using ICD-10 codes for more than four months now, and most practices have seen success so far. But don’t let the relief over simple implementation stop your learning process. Dig deeper into certain code ranges to ensure you are truly assigning the most specific code for the clinical scenario your urologist is documenting.

Take neoplasm coding, for example. Coding neoplasms can only get easier if you know how to interpret the pathology report and where to spot the correct code in the listing. Confirm the anatomical site and get the terminology right to narrow choices for the appropriate code assignment. Here is what experts advise for ICD-10-CM neoplasm coding.

Step 1: Start with Histologic Term

Just as with ICD-9-CM, if the pathology report documents a histological term for the neoplasm, such as “adenocarcinoma” or “myolipoma,” look first to the Alphabetical Index. That is where the code reference and any other instructions about the condition that you need to know will be.

Histologic terms in the Alphabetical Index typically include direction about how to categorize the neoplasm’s behavior. You will need that information when you take Step 2; turning to the Neoplasm Table — to help you ‘zero in’ on the right code.

Don’t miss: There are certain histological terms that list the correct codes in the Alphabetical Index and do not refer to the Neoplasm Table. Examples include adrenal adenomas and melanoma of the scrotum.

That’s why you should “always check the Alphabetical Index first,” says Lisa Selman-Holman, JD, BSN, RN, COS-C,HCS-D, HCS-O, AHIMA approved ICD-10-CM trainer/ ambassador of Selman-Holman & Associates, LLC, CoDR — Coding Done Right and Code Pro University in Denton, Texas.

Step 2: Turn to the Neoplasm Table

After checking the Alphabetical Index, your next stop when using ICD-10-CM to code for a neoplasm is the Neoplasm Table. You’ll find the table just after the end of the Alphabetical Index in your coding manual, rather than under “N” in the Alphabetical Index as it was in ICD-9-CM, says Joan Usher, BS, RHIA, COS-C, ACE, AHIMA-approved ICD-10-CM Trainer with JLU Health Record Systems in Pembroke, Mass.

To locate the appropriate code in the Neoplasm Table, know the affected anatomical site (such as skin, abdomen, ureter, penis, or other site) and the neoplasm’s behavior. The primary classifications of behavior are:

• Malignant — the neoplastic cells have the capacity to spread to distant sites;
• Benign — the neoplastic cell type is not expected to spread;
• Uncertain behavior — the neoplastic cells are not clearly a type that is benign or malignant.

The neoplasm table also lists codes for “unspecified behavior.” Use this if the pathology report does not provide a clear indication of the neoplastic cell type or behavior.

There’s more to malignant: The neoplasm table further subdivides malignant neoplasms based on certain characteristics of the specific tumor specimen. For instance, the table lists “Carcinoma in situ” (Ca in situ), which means that the neoplasm is currently contained at the site within the lining of the organ, even though it is a malignant type that has the potential to spread. Other malignant neoplastic designations in the Neoplasm Table include “primary,” which means that the neoplasm being diagnosed is at its site of origin, or “secondary,” which means that the neoplasm being diagnosed has spread to the current site from a distant primary site.

Step 3: Verify Using Tabular List

Once you locate the neoplasm description in the Alphabetical Index and the Neoplasm Table, you should have a code number, however do not assign that code and stop there. You should never finalize a diagnosis without verifying the code in the Tabular List section of the ICD-10-CM text.

Checking the code against the Tabular List provides guidance on laterality, site location, gender, whether you need to use an additional code to report your patient’s condition, as well as excludes notes which may be applicable before code assignment, Usher says.

Step 4: Follow Sequencing for Primary and Secondary Foci

If you are coding a malignant neoplasm, you may be dealing with a metastatic condition, where the neoplasm has spread from one site to another. When coding metastatic disease at a secondary site, you’ll usually code the primary site before the metastasis, but that is not always the case.

Exception: If the secondary site is the focus of care, or if the primary site has been resolved, code the metastasis first.

Step 5: Get the Site Rules Right

When coding a malignant neoplasm that overlaps two or more contiguous sites, you’ll report the “multiple sites” code ending with character “8” in most cases. For example, if your urologist documents overlapping lateral and dome bladder cancer, “you’ll use the .8 (C67.8, Malignant neoplasm of overlapping sites of the bladder),” showing that the tumor is present in more than one site, says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

When a patient has multiple neoplasms of the same organ/site that are not next to each other and the sites do not overlap, such as tumors in different parts of the bladder, you’ll assign codes for each affected site.