General Surgery Coding Alert

Wait for the pathology report and carefully review ICD-9 tables for claims success

Frequently, selecting a diagnosis to accompany lesion removal is a greater challenge than choosing the appropriate CPT code. You can ease your troubles by following four, expert-approved tips.

Tip 1: Don't Make a Move Without the Path Report

You shouldn't even try to choose a neoplasm diagnosis until you've received the results of the pathology study.

"Without the pathology report, you're just guessing what kind of neoplasm you're dealing with," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Landsdale, Pa. Even if the surgeon has a strong suspicion that the neoplasm is cancerous, for instance, the diagnosis is still unconfirmed until you get the pathology results.

And entering a wrong diagnosis can have serious effects.

You don't want to label a patient as having cancer if the diagnosis isn't certain, warns Darren Carter, MD, president of Provistas Inc. in New York City. A cancer diagnosis is a red flag for insurers that could make it more difficult for the patient to gain medical coverage.

At the same time, if you fail to indicate a malignant lesion when present, you limit the treatment options that the insurer may accept at a later date.

Bottom line: Choosing a diagnosis is hard enough, so be sure you have all the relevant information before you proceed.
 
Tip 2: Identify the Type of Neoplasm

With the pathology report in hand, you should be able to determine if the neoplasm is benign or malignant and, if malignant, the type of malignancy (primary, secondary or in situ) present (See "Get a Grip on Neoplasm Terminology," for more on the different types of neoplasms).

"A pathology report is usually a brief statement that clearly identifies the type of neoplasm," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "Using this information, you're ready to go to ICD-9 and find the diagnosis code that fits."

Tip 3: Consult ICD-9 Vol. 2

Next, you should go to the alphabetic index (vol. 2) of the ICD-9 manual and look up the main term that describes the neoplasm type.

Don't skip to the neoplasm table: Although the alphabetic index will often direct you to the neoplasm table, checking the index is not a wasted step.

"You won't find all the codes you need in the neoplasm table," Jandroep says. "Certain types of conditions are only listed in the index, and in other cases, using the index will save time and reduce confusion."

For example, if you look up malignant melanoma of the lip in the alphabetical index, you will find code 172.0 (Malignant melanoma of skin; lip). In this case, you do not need to consult the neoplasm table elsewhere in volume 2 - although you should still confirm the code by checking it against the tabular index, (vol. 1 of ICD-9).
 
Tip 4: Head for the Neoplasm Table

If the alphabetical index doesn't provide the information you need, you should next consult the neoplasm table.

For example, the patient may exhibit malignant mesothelioma. If you find this term in the ICD-9 index, the entry will direct you to the neoplasm table, stating, "see also, neoplasm, by site, malignant."

If you find the entry for "breast" in the neoplasm table, you will notice that the codes are further differentiated according to the exact area of the breast and the type of malignancy. Because the surgeon removed the sample from the lower-inner quadrant and the pathology report verifies primary malignancy, you should choose 174.3 (Malignant neoplasm of female breast; lower-inner quadrant).

In a second example, if you look for adenocarcinoma of the rectum in the index, you'll find directions to "neoplasm by site, malignant." You then look for "rectum" in the neoplasm table. Consulting the path report, you notice the neoplasm is in situ, and you therefore report 230.4 (Carcinoma in situ of digestive organs; rectum).

"Skin" lesions require special consideration: For neoplasms that occur on or near the skin of an anatomic site, you should assign a diagnosis for skin - not for the body area in question. For example, if the surgeon removes a lesion from the skin of a woman's breast that pathology determines is benign, you should report 216.5 (Benign neoplasm of skin; skin of trunk, except scrotum).

Always check the tabular list: In all cases, before assigning a final code, verify the diagnosis you have selected in the tabular list (vol. 1) of ICD-9, Jandroep advises.