Wiki Metastatic prostate cancer

[cpccoder2008]

I'm coding this inpatient chart and having trouble with the diagnosis.

PRINCIPAL DISCHARGE DIAGNOSES:
1. Shortness of breath secondary to bilateral malignant pleural effusion, status post Pleurx catheter placement.
2. Newly diagnosed right upper lobe adenocarcinoma, probably lung cancer versus metastatic prostate cancer.
SECONDARY DISCHARGE DIAGNOSES:
1. Metastatic prostate cancer being followed by ______ hospital.



Throughout the stay the prostate cancer is being referred to as metastatic prostate cancer with mets to the bone and liver. I may be reading into this wrong but after looking at the discharge it seems to be as if the lung cancer is primary with mets to prostate, bone and liver. Would I be correct to say I would use 162.4 as principle and 511.81, 198.82 and 198.5 as secondary ?

Thanks

 

[mitchellde]

I do not see where you are getting the bone and liver from..
Being inpatient facility you can code probably as though it exisits also in a this vs that scenario you are instructed to code both... I see primary Prostate cancer with probably mets to the lung, or primary prostate with primary lung CA
he states probably lung cancer (primary lung) vs metastatic prostate cancer (prostate primary mets to the lung)
and then the malignant pleural effusion

 

[cpccoder2008]

Sorry it was in the rest of the discharge summary but I didn't post the whole thing. After reviewing the chart the physician later states that the lung cancer is a new primary and the prostate is the mets. It was the on call physician who completed the discharge summary so he didn't treat the patient the entire stay. The pleural effusion was also negative for any malignancy on the cytology report and documented through out the stay. There were a few other issues I had requiring me to do a query. I should have read the entire chart before posting but after coding all day your mind seems to wonder off a bit.

Thanks