Oncology & Hematology Coding Alert

Learn how to report the diagnosis for ED conditions in a patient with carcinoma.

Chapters 2, 3 and 4 of the ICD-10-CM manual provide directions on reporting neoplasms, diseases of the blood and blood-forming organs, and endocrine and metabolic diseases. Here are tips for reporting these conditions from Caral Edelberg, CPC, CMPA, CAC, CCS-P, CHC, an AHIMA Certified ICD-10-CM Instructor and President, Edelberg and Associates.  

Best practices: Make sure your physician documents a specific diagnosis. “We won’t know for some time how payers will react to this new coding system with determining medical necessity, so it’s best to work with providers now to educate them on increasing the specificity of diagnoses,” she advises. 

Primary Site and Behavior Drive Neoplasm Code Choices

ICD-10-CM Chapter 2, Neoplasms, contains numerous broad groups of neoplasms, whether functionally active or not.  Check the medical chart documentation to help you determine the primary site and nature of the neoplasm. When functionally active, you can use an additional code from Chapter 4 – Endocrine, Nutritional and Metabolic Diseases E00 – E89, to identify the activity associated with the neoplasm.  

The morphology contained in Chapter 2 classifies neoplasms primarily by site, with groupings for behavior, malignant, in situ, benign, etc.  

Heads up: Two key points to remember are:

(1) You should classify primary malignant neoplasms overlapping site boundaries as overlapping lesions, and 

(2) You should code malignant neoplasm of ectopic tissue to the site/location of the tissue. 

Tackle This Dehydration Issue

If a malignancy results in dehydration, and the dehydration is being managed in the your oncology practice, you should consider the admission/encounter as management of dehydration due to malignancy, says Edelberg.  

What to document: Oncologists need to document dehydration when applicable to avoid the less specific codes involving NEC (Not elsewhere classified) descriptors.  When sequencing dehydration resulting from malignancy, the dehydration needs to be sequenced first, followed by the code(s) for the malignancy.  If an admission/encounter is for a neoplasm-related pain (G89.3), this should be specified by the oncologist as well. The pain code will be sequenced first if the sole purpose of the encounter is for pain control/pain management, says Edelberg.  

Check Out Neoplasm of Digestive Organs

Did you know malignant neoplasms of liver are included in the malignant neoplasm of digestive organs section (C15-C26)?  This broader section also includes;

• malignant neoplasms of esophagus (C15);
• malignant neoplasm of stomach (C16);
• malignant neoplasm of small intestine (C17), colon (C18), recto-sigmoid junction (C19), rectum (C20), anus and anal canal (C21), liver and intrahepatic bile ducts (C22), gallbladder (C23);
• other unspecified part of biliary tract (C24), 
• pancreas (C25); 
• other and ill-defined digestive organs (C26).  
• Liver neoplasm excludes:
• malignant neoplasm of biliary tract;
• secondary malignant neoplasm of liver and intrahepatic bile duct.  

Common to oncology, coding of alcohol abuse/dependence will require additional codes to identify:

• alcohol related disorders (F10); 
• hepatitis B (B16-, B18-0-B18-1); and
• hepatitis C (B17.1_,  B18.2).  

Liver includes liver cell carcinoma, intrahepatic bile duct carcinoma and hepatoblastoma, angiosarcoma of liver.

Common ED Hemorrhage Presentations Require More Specific Codes 

You must specify hemorrhagic conditions (D69) using codes from Chapter 3, Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism, includes codes from D50-D89.  This chapter includes conditions common to the emergency department and associated with puerperal and other hemorrhagic conditions.  

Watch the terminology.  ICD-10-CM includes purpura and other hemorrhagic conditions like allergic purpura, qualitative platelet defects, other nonthrombocytopenic purpura, immune thrombocytopenic; purpura, other primary thrombocytopenia, secondary thrombocytopenia to include post-transfusion purpura, Edelberg warns.

Example:

• C22.0 liver cell carcinoma
• D69.6 Thrombocytopenia, unspecified

Don’t Forget to Follow Up Active Neoplasm Codes with a Chapter 4 Diagnosis

Chapter 4.  Endocrine, Nutritional and Metabolic Diseases (E00-E89) does not contain neoplasms classified in Chapter 2.  Rather, codes in this chapter are used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere, Edelberg explains. 

What to look for: Conditions common to oncology contained in this section are diabetes mellitus with additional classifications for disorders of glucose regulation and pancreatic internal secretions, disorders of other endocrine glands, malnutrition, other nutritional deficiencies, overweight, obesity and other hyperalimentation and metabolic disorders.

How to code: For diabetes mellitus, code first the type of diabetes with and underlying condition then use additional codes to identify insulin use (Z79.4-, Long term [current] use of insulin). For example, Type 2 diabetes mellitus with left heel and mid foot ulcer (E11.621) limited to breakdown of skin, the location of the foot ulcer would also be required (L97.421).  The numerous listings in this section often require special attention to detail and the additional conditions.  Laterality is generally included in the code set as well, Edelberg adds.

If the physician states “chronic kidney disease” as a complication, it will be necessary to identify the stage of chronic disease:

• stage 1 – (N18.1)
• stage 2 – mild (N18.2)
• stage 3 – moderate  (N18.3)
• stage 4 -  severe (N18.4)
• stage 5 – N18.5.