Urology Coding Alert

Question: What diagnosis would I use for "muscleinvasive bladder cancer post-radical cystectomy with neobladder formation and adjuvant chemotherapy with gemcitabine and cisplatin"?

Ohio Subscriber

Answer: There is no diagnosis code that will delineate stage (invasiveness) or grade (cellular histology) of bladder tumors. Since the urologist is still treating the patient's bladder cancer with chemotherapy, code the cancer diagnosis -- 188.X (Malignant neoplasm of bladder) -- as the primary diagnosis, irrespective of the presence or absence of tumor, clinical stage.

Then, use V58.11 (Encounter for antineoplastic chemotherapy) as the secondary diagnosis. Other secondary diagnoses that would be appropriate coding include V45.74 (Acquired absence of organ; other parts of urinary tract) and V44.8 (Artificial opening status; other artificial opening status).