Oncology & Hematology Coding Alert

Oral cancer is on the rise, so you'll need to be prepared to code cases that come into your practice. Put your best foot forward by boosting your tongue anatomy knowledge using our diagrams and refreshing your knowledge of when to use primary, secondary, andcarcinoma in situ codes.

A primary malignancy is one arising from the cells of the biopsied neoplasm, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.

Example: A biopsy shows that a male patient has a tongue neoplasm. It is malignant and comprises cancer cells from the area of excision (as opposed to cancer cells that originated elsewhere -- such as the lip -- and spread to the tongue). Code a primary tongue malignancy using

141.x (Malignant neoplasm of tongue).

The 141.x range includes the following codes:

• 141.0 -- ... base of tongue

• 141.1 -- ... dorsal surface of tongue

• 141.2 -- ... tip and lateral border of tongue

• 141.3 -- ... ventral surface of tongue

• 141.4 -- ... anterior two-thirds of tongue, part unspecified

• 141.5 -- ... junctional zone

• 141.6 -- ... lingual tonsil

• 141.8 -- ... other sites of tongue

• 141.9 -- ... tongue, unspecified.

Whenever possible, you want to report a primary neoplasm using the most specific code. If the site is not documented and you can't get clarification from the oncologist, you'll have to use 141.9.

You also may face coding a neoplasm that involves more than one site. For a neoplasm covering contiguous or overlapping sites -- or if the oncologist can't determine the point of origin -- use 141.8 (... other sites of tongue).

Caution: Some coders find reporting 141.8 or 141.9 tempting when payers don't cover base of tongue code 141.0 for IMRT. But remember that correct coding requires you to report the most appropriate code. If your practice faces this dilemma, get an advance beneficiary notice (ABN) rather than defaulting to an improper code.

You should use secondary codes when the neoplasm is the result of metastasis from another organ or area, such as the lymph nodes, throat, or brain, or when the primary malignancy invades the organ in question from an adjacent structure or organ.

In other words, secondary malignancies are "metastatic cancer -- or where the cancer has spread to," says Julie Keene, CPC, CENTC, coding and reimbursement specialist for UC Physicians in Cincinnati.

Example: The pathology report for a tongue neoplasm indicates that the cancer is a secondary malignancy with the stomach as the origin. You should report a secondary neoplasm code: 198.89 (Secondary malignant neoplasm of other specified sites; other).

"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, Bucknam says.

Translation: "The cancer is located in the cells and hasn't spread to surrounding tissues," Keene says.

For the tongue, 230.0 (Carcinoma in situ of digestive organs; lip, oral cavity, and pharynx) is appropriate for a carcinoma in situ.

Key: The pathology report must state "in situ" for you to use this code because it is a histopathological diagnosis. Just knowing the cancer cells are confined to the site of origin isn't enough reason for you to use the in situ code.

As the chart on page 84 indicates, your coding options for a secondary neoplasm (198.89) and carcinoma in situ (230.0) are the same regardless of location on the tongue.

Choosing the most specific primary neoplasm code, on the other hand, requires a deeper knowledge of tongue anatomy. Use our diagrams on page 84 to help you pinpoint the most appropriate code.