Interpret Guideline I.C.2 Correctly for Flawless Neoplasm Dx Coding
Be sure to take note of these helpful examples. If you want to hone your ability to code neoplasms, the best place to begin is to familiarize yourself with ICD-10-CM guidelines, specifically the chapter-specific guidelines found in section I.C.2. Following them to the letter will help you zero in on the most accurate diagnosis code for any patient encounter with your oncologist. Altogether, the guideline outlines four specific coding concepts you should apply each time you assign a code to a patient visit. 1. Let the Reason for the Encounter Determine the Code This advice sounds easy, but in reality, it’s a little more complicated than it seems when it comes to neoplasm coding. Guideline I.C.2.a tells you that “if the malignancy is chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site, designate the primary malignancy as the principal/first-listed diagnosis.” This guideline echoes the overarching ICD-10-CM Guideline IV.G, which tells you to “list first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.” But there are two exceptions to this rule in oncology coding. First, I.C.2.b tells you that if the treatment at the encounter is directed toward a metastatic or secondary neoplasm, you will designate the secondary neoplasm as the principal diagnosis “even though the primary malignancy is still present.” Second, as Guideline I.C.2.a tells you, if the encounter is mostly for “the administration of chemotherapy, immunotherapy or external beam radiation therapy,” you should “assign the appropriate Z51.- code as the first-listed or principal diagnosis, and the underlying diagnosis or problem for which the service is being performed as a secondary diagnosis.” Example: A patient with prostate cancer reports to your practice for chemotherapy. For this encounter, you’ll assign Z51.11 (Encounter for antineoplastic chemotherapy) as the principal diagnosis before the cancer diagnosis code: C61 (Malignant neoplasm of prostate). 2. Know How to Sequence Complications Encounters where a patient is being treated for complications resulting from their cancer are coded slightly differently. To code encounters for treatment only for anemia associated with the malignancy, you’ll code the neoplasm first, followed by D63.0 (Anemia in neoplastic disease) or another appropriate anemia code. To code encounters for treatment only for anemia associated with chemotherapy, immunotherapy, and radiation therapy, you’ll select the appropriate code for the anemia first, followed by the appropriate neoplasm code, and either T45.1X5- (Adverse effect of antineoplastic and immunosuppressive drugs) or Y84.2 (Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure) depending on the type of therapy causing the anemia. To code encounters for treatment only for dehydration associated with the malignancy, you’ll sequence the dehydration first using E86.0 (Dehydration) followed by the code(s) for the malignancy. To code encounters for treatment only for complications associated with surgery for the malignancy, you’ll assign the code for the complication only. Example: A patient taking chemotherapy for breast cancer in the central portion of their right breast comes in to see your oncologist. In the encounter, the provider evaluates and manages the patient for anemia due to the chemotherapy. It is the patient’s first encounter for this particular condition. For this encounter, you’ll assign: 3. Understand Overlapping Site Coding The general guideline for I.C.2 also tells you “a primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 (‘overlapping lesion’), unless the combination is specifically indexed elsewhere.” “For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast,” however, the guideline tells you to assign “codes for each site.” Example of non-overlapping neoplasm site coding: A provider diagnoses a patient with multiple neoplasms in the right main bronchus, the right upper lobe, and the right lower lobe that are not contiguous. In this case, you will code: Example of overlapping neoplasm site coding: Your provider diagnoses a patient with multiple contiguous neoplasms in the right lung. In this case, you’ll use C34.81 (Malignant neoplasm of overlapping sites of right bronchus and lung) as the neoplasms in the right lung are touching each other. Remember: The 4th character 8 is used throughout the malignant neoplasm codes to specify overlapping, or contiguous, neoplasms. 4. Get a Handle on the Personal History and In Remission Codes A perennial problem in oncology coding is knowing when to apply a personal history of malignant neoplasm code or an “in remission” code. That’s where Guideline I.C.2.m comes in, which tells you to use “a code from category Z85, Personal history of malignant neoplasm … when a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site.” Example: At the encounter, a provider examines a patient who has had a melanoma on the right forearm excised at a previous encounter. All margins were clear, the patient is not currently receiving any treatment, and there is no current evidence of disease in the supporting documentation. In this case, you can assign a personal history code such as Z85.820 (Personal history of malignant melanoma of skin). Exception: For “leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms,” you have the option of using a personal history code or an “in remission” code per Guideline I.C.2.n. Here, the trick is to check provider documentation to determine if the remission is partial or full. Partial remission means that some of the signs and symptoms of the condition are still present, whereas full remission meets the definition applied to the personal history codes outlined in Guideline I.C.2.m. To code leukemia and conditions coded to C90.- in partial remission you’ll assign the 5th character 1 to the appropriate code. Example: At the encounter, your provider documents that a patient with acute myeloid leukemia (AML) is still showing signs and symptoms of the condition. In this case, you’ll assign C92.01 (Acute myeloblastic leukemia, in remission) if provider documentation supports it. To code leukemia and conditions coded to C90.- in full remission you’ll use a personal history code such as Z85.6 (Personal history of leukemia) or Z85.79 (Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues). Example: At the encounter, your provider documents the patient with AML is no longer showing signs and symptoms of the condition. In this case, you’ll assign Z85.6 if provider documentation supports it. Remember: If in doubt, “If the documentation is unclear as to whether the leukemia has achieved remission, the provider should be queried,” per Guideline I.C.2.n. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
