Oncology & Hematology Coding Alert

Condition Spotlight:

Stay Alert to These Different Ways to Document Cancer and Fatigue

Published on Wed Feb 23, 2022

These two scenarios will help you determine causality.

Fatigue and weakness are common in cancer patients, but capturing them with ICD-10-CM codes is a little more difficult than you might think. For one, the terms are not interchangeable, so your coding for the conditions needs to be precise and specific. Second, you must determine whether your provider has documented a link between the conditions and the patient’s cancer, or whether the conditions are caused by the course of treatment the patient is undergoing for the condition, before locating the precise code.

Here, then, is a decision tree to help you pinpoint the correct codes when you see malaise, fatigue, weakness, or other associated conditions documented in a cancer patient’s record.

Understand the Problematic Etiology

According to the American Cancer Society, “the causes of cancer-related fatigue … might be from the cancer itself and/ or a side effect of the cancer treatment” (www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fatigue/what-is-cancer-related-fatigue.html). Knowing this helps you understand that coding the condition is not as simple as reaching for a signs and symptoms code.

If your provider does document a link between the cancer and the patient’s fatigue, then you may be able to assign R53.0 (Neoplastic [malignant] related fatigue). But your coding doesn’t stop there, as the instructional note for R53.0 tells you to “code first the associated neoplasm.” And that may not be the only code you will assign in this situation.

Example: Your provider documents that a patient has fatigue due to anemia, which in turn is caused by the patient’s acute myeloblastic leukemia. Your coding in this situation could look something like this:

C92.00 (Acute myeloblastic leukemia, not having achieved remission) for the leukemia
D63.0 (Anemia in neoplastic disease) for the anemia caused by the leukemia
R53.0 for the fatigue caused by the anemia

Why? You have two sets of instructional notes, one each for D63.0 and R53.0, that tell you to code first the neoplasm, which would place C92.00 at the top of the coding hierarchy in this scenario. But what if your provider documents that the patient’s fatigue is due to the treatment the patient is receiving for the cancer?

Now, instead of R53.0, you’ll have to assign some different codes to paint the whole picture of the patient’s condition. The fatigue code itself will change to R53.83 (Other fatigue). So, too, will the code for the cause of the fatigue, which you will now report with an external cause code: T45.1X5- (Adverse effect of antineoplastic and immunosuppressive drugs). Per the T45 category instructions, you’ll also add a 7th character A (initial encounter), D (subsequent encounter), or S (sequela), depending on the stage of patient care.

Example: Your provider sees a patient and documents they have fatigue due to anemia. This time, however, the provider has determined the anemia is due to the chemotherapy the patient is receiving for their acute myeloblastic leukemia. Therefore, you’ll code the following:

D64.81 (Anemia due to antineoplastic chemotherapy) for the anemia
T45.1X5- for the cause of the anemia, which is the chemotherapy treatment
C92.00 for the leukemia
R53.83 for the fatigue

Why? “D64.81 would be the principal diagnosis in this case,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado. “A recent issue of AHA ICD-10-CM Coding Clinic [Volume 8 Number 3 2021] presents an analogous coding scenario, which tells you ‘although there is an Excludes 1 note at category D64, Other anemias, which means the two codes [D64.- and a code from C92.-] cannot be assigned together, both codes are required to capture anemia due to chemotherapy and acute myeloid leukemia. These are separate conditions, which are unrelated, as the anemia was caused by the chemotherapy not the AML and thus an exception to the Excludes1 note,’” Loya adds.

Understand the Difference Between Fatigue, Weakness, and Malaise

In the second scenario, you would use the fatigue code if that was what your provider documented. But your provider could equally document symptoms such as malaise, exhaustion, lethargy, lack of energy, and so on. This means you should be aware of the different R53 codes and their synonyms that may be at your disposal. They would include:

R53.1 (Weakness), which has asthenia NOS as a synonym
R53.81 (Other malaise), which has chronic debility, debility NOS, general physical deterioration, and malaise NOS as synonyms
R53.82 (Chronic fatigue, unspecified), which has chronic fatigue syndrome NOS as a synonym
R53.83, which has lack of energy, lethargy, and tiredness as synonyms

A note about ICD-10-CM inclusion terms: “According to ICD-10-CM guideline I.A.11, the list of terms under a code are referred to as inclusion terms. They include synonyms for some codes and, when listed under an ‘other specified’ code, indicate conditions represented by that code,” says Leah Fuller, CPC, COC, senior consultant, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

This means you should “always refer to the Alphabetic Index as a first step prior to consulting the tabular list as the inclusion terms are not an exhaustive list and the Alphabetic Index can provide additional terms that will lead you to the appropriate code choice,” Fuller advises.

Most important: Ultimately, as with any coding scenario, provider documentation must drive your code choice. “If the provider’s documentation regarding the cause of the patient’s fatigue is unclear, you will need to clarify with the provider and not assume causality before having the supporting definitive documentation in the patient’s record for the correct code choice,” Loya notes.