Urology Coding Alert

Avoid claim rejections with simple primary and secondary know-how

You know the routine: The lab returns a pathology report for a prostate biopsy and the report states, "transitional cell carcinoma from the urinary bladder." Now you can simplify how you approach these tough neoplasm coding conundrums with this quick review of the relevant terminology you'll face when coding biopsy reports.

Malignant and Benign Define Main Categories

When looking at the neoplasm table in your ICD-9 Codes book, you will find two main categories of neoplasms: malignant and benign. We're going to start with three subcategories for the malignant category:

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 prostate. It is malignant and comprises  cancer cells from the area of excision (as opposed to cancer cells that originated elsewhere and spread to the breast). Code for a primary malignancy, using 185 (Malignant neoplasm of prostate).

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, liver, lungs or brain or when the primary malignancy invades the organ in question from an adjacent structure or organ.

Example #1: The urologist removes a neoplasm from the prostate, and the pathology report indicates that the lump is a secondary malignancy with the lungs as the origin. You should report a secondary neoplasm code: 198.82 (Secondary malignant neoplasm of other specified sites; genital organs).

Example #2: The urologist removes a neoplasm from the prostate and finds a transitional cell carcinoma, which represents direct invasion of a malignant tumor from the adjacent urinary bladder into the prostate gland. Again, report a secondary neoplasm code: 198.82.

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 - such as those involving the bladder - there is no guarantee that removal of the mass will totally eradicate the cancer.

In situ may also indicate "malignant cellular changes confined to a membrane or lining," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook."We diagnose bladder carcinoma in situ when localized malignant cellular changes are confined to the mucosa [bladder lining] without spreading beyond the basement membrane." In those cases, the diagnosis code is ICD-9 233.7 (Carcinoma in situ of breast and genitourinary system; bladder)," Ferragamo says.

No Cancer = No Malignancy

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

Benign: Benign neoplasms are cancer-free.
 
Example: For a fibroadenoma of the prostate, which does not spread, report a benign neoplasm - 222.2 (Benign neoplasm of male genital organs; prostate). Benign neoplasms may return after removal, but they are noninvasive, Bucknam says.

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.

Example: Benign adenomatous polyps are at high risk for becoming malignant if they remain undiagnosed and untreated.

"Uncertain behavior" implies that a doctor has previously biopsied, "but a definitive diagnosis could not be made, hence the need for a repeat biopsy and tissue examination," Ferragamo says.

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 surgeon's documentation didn't indicate the skin lesion's type.

Unspecified: You should only use this category when the surgeon cannot determine the nature of the neoplasm. If the urologist excises a bladder tumor but does not wait for the pathology report, for example, the unspecified ICD-9 code 239.4 (Neoplasms of unspecified nature; bladder) is the only code that should be used.