Urology Coding Alert

Question: We recently got audited and got dinged for diagnosis coding in office visits, specifically with malignancies. I just did a provider education with my physicians on that, but one of them raised this question: They have a few patients on a Bacillus Calmette- Guerin (BCG) course to treat intermediate to high risk of recurrence of bladder cancer. The patient is in between having an active malignancy (C67.x) to treat and history (Z85.51). There’s no visible lesion (D49.4) to resect, but there might be a non-visible carcinoma in situ the BCG might affect. What would be the appropriate diagnosis to report for these visits?

AAPC Forum Subscriber

Answer: As long as the urologist is “treating” the patient with BCG, you should report C67.- (Malignant neoplasm of bladder) or D49.4 (Neoplasm of unspecified behavior of bladder). You’ll also report Z51.11 (Encounter for antineoplastic chemotherapy). Once there is no longer active treatment, use the personal history code: Z85.51 (Personal history of malignant neoplasm of bladder).

Why: The ICD-10-CM guidelines indicate that a personal history code from category Z85 should be assigned when:

• The primary malignancy has been previously excised or eradicated; and
• There is no further treatment directed to that site; and
• There is no evidence of any existing primary malignancy.

According to the ICD-10 guidelines Section I.C.2.m, “when a primary malignancy has been excised but further treatment, such as additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is complete.”

Therefore, since the patient is still receiving BCG, in this case, you should use the bladder cancer diagnosis, not the personal history code.

Beyond the Dx: For the instillation procedure itself, report 51720 (Bladder instillation of anticarcinogenic agent (including retention time)). Then add your medication code J9030 (BCG live intravesical instillation, 1 mg) based on the amount your urologist instilled.