General Surgery Coding Alert

Question: When diagnosing neoplasms, how should I choose from among the various categories (primary malignant, secondary malignant, etc.)? What's the difference between -uncertain- and -unspecified-?


California Subscriber


Answer: ICD-9 divides neoplasms into two main categories: malignant (cancerous) and benign (non-cancerous). Within each main category, there are subclassifications.

A primary malignancy is one arising from the cells found where the surgeon biopsied the neoplasm.

A secondary neoplasm is the result of metastasis and forms a new focus of malignancy elsewhere, such as the lymph nodes, liver, lungs or brain, or when the primary cancer has invaded adjacent structures.

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. In some cases, however--such as those involving the breast (233.0), bladder (233.7) and cervix (233.1), for instance--there is no guarantee that removing the mass will totally eradicate the cancer.

Benign neoplasms are cancer-free. For example, for a fibroadenoma of the breast, which does not spread, you should report a benign neoplasm (217).

Benign neoplasms may return after removal, but they are noninvasive.

Also, there are categories for -uncertain behavior- and -unspecified.-

If the pathology report returns with indications of atypia or dysplasia, the neoplasm is -in transition- from benign to malignant and is therefore -uncertain.- 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.

You should use the -unspecified- diagnosis only when the surgeon cannot determine the nature of the neoplasm. This diagnosis would be very rare in the physician setting because you would normally wait for the biopsy report before assigning a diagnosis. One possible exception is when the surgeon destroys the lesion and there is no specimen to send to the lab. But  the surgeon would usually only take such a step if he is sure he is not dealing with a malignancy.

Use caution: 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.