Oncology & Hematology Coding Alert

Here's what to do when treatment aims change. Ever get confused between first-listed and second-listed diagnoses and primary and secondary cancer sites? Testimony that came up during an appeal made subscriber Rachel Morales, CPC, of Harrington Physicians Inc. in Amarillo, Texas, wonder if she's been coding the diagnosis wrong when her oncologist treats a secondary, metastatic site. The good news: Morales got the coding right, and here's what you can learn from her experience. When Cancer Spreads, Adapt Coding The situation: Morales gives our experts plenty of details. The patient was originally diagnosed with grade 3, stage IIA endometrial adenosquamous carcinoma, which Morales coded 182.0 (Malignant neoplasm of body of uterus; corpus uteri, except isthmus) in September 2005. The patient had her uterus removed and refused chemo at the time, but, several months later, she presented with upper respiratory infection symptoms. The endometrial cancer had metastasized to a lung. The coding: The pathology report read "positive for metastatic recurrent endometrial carcinoma," which Morales coded 197.0 (Secondary malignant neoplasm or respiratory and digestive systems; lung). The physician tried different drug combinations for about a year, but these didn't help the patient. So the physician ordered Gemzar -- J9201 (Gemcitabine HCl, 200 mg) -- which does not have an indication on Morales- Medicare local coverage determination (LCD) for diagnosis codes 182.0 or 197.0; though it does for 162.8 (Malignant neoplasm of trachea, bronchus, and lung; other parts of bronchus or lung). "Gemzar was used on the patient for about four months with some improvement," Morales said. The drug helped, but the payer denied the claim for services. In billing the Gemzar, the order in which Morales entered diagnoses was 197.0 first-listed with 182.0 second-listed. In other words, the secondary neoplasm became the primary diagnosis. Problem: Medicare Didn't Cover J9201 But Morales- Medicare carrier won't pay for Gemzar for codes 197.0 or 182.0. "We appealed several times, with letters of medical necessity and other various documents, but always with a denial," Morales says. Successful appeal: The company that supplies the clinic's Gemzar appealed at the same time, Morales said. During the appeal, the company's representative, a registered nurse, testified that had the doctor's office used 162.8 as the first-listed diagnosis there would have been no problem. But this statement raises an important question. Which Code Should You Use? Difference of opinion: According to Morales, the RN said the malignancy treated should be the first-listed diagnosis; when the patient presents for treatment of the secondary site only, the secondary neoplasm becomes the first-listed diagnosis. That's true, says Janae Ballard, CPC, CPC-H, CPC-E/M, PCS, FCS, ACS-EM, revenue coding analyst at the Virginia Mason Medical Center in Seattle, but it's no cause to change the actual diagnosis from 197.0 [...]