Part B Insider (Multispecialty) Coding Alert

Published on Thu Jan 06, 2005 PDF

Haste makes waste-wait for the pathology report and cut out claim denial

It may be easy to choose a cancer excision code, but nailing down the neoplasm diagnosis is a much trickier task. Follow these four expert tips to produce correctly coded claims.

Tip 1: Don't Make a Move Without the Path Report

Don't even try to choose a neoplasm diagnosis until you've received the results of the pathology study.

"Without the pathology report, you're just guessing what kind of neoplasm you're dealing with," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Landsdale, PA. Even if the physician has a strong suspicion that the neoplasm is cancerous, for instance, the diagnosis is still unconfirmed until you get the pathology results.

If you enter the wrong diagnosis, it can have serious effects.

You don't want to label a patient as having cancer if the diagnosis isn't certain, warns Darren Carter, MD, president of Provistas Inc. in New York City. A cancer diagnosis is a red flag for insurers that could make it more difficult for the patient to gain medical coverage.

However, failure to indicate a malignant lesion when present will limit the coding for the current procedure and can also limit the treatment options that the insurer may accept at a later date.

Bottom line: Choosing a diagnosis is hard enough, so be sure you have all the relevant information before you proceed.

Tip 2: Identify the Type of Neoplasm

With the pathology report in hand, first determine if the neoplasm is benign or malignant and, if malignant, the type of malignancy (primary, secondary or in situ) present (see "Understand Uncertain, Unspecified and In-Situ" for more on the different types of neoplasms). 

"A pathology report is usually a brief statement that clearly identifies the type of neoplasm," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "Using this information, you're ready to go to ICD-9 and find the diagnosis  code that fits."

Tip 3: Consult ICD-9 Vol. 2

Next, you should go to the alphabetic index (vol. 2) of the ICD-9 manual and look up the main term that describes the neoplasm type.

Don't skip to the neoplasm table: Although the alphabetic index will often direct you to the neoplasm table, checking the index is not a wasted step.

"You won't find all the codes you need in the neoplasm table," Jandroep says. "Certain types of conditions are only listed in the index, and in other cases, using the index will save time and reduce confusion."

For example, if you look up malignant melanoma of the lip in the alphabetical index, you will find code 172.0 (Malignant melanoma of skin; lip). In this case, you do not need to consult the neoplasm table elsewhere in volume 2 - although you should still confirm the code by checking it against the tabular index (vol. 1 of ICD-9).

Tip 4: Head for the Neoplasm Table

If the alphabetical index does not provide the information you need, you should next consult the neoplasm table.

For example, the patient may exhibit malignant mesothelioma. If you find this term in the ICD-9 index, the entry will direct you to the neoplasm table, stating, "see also, neoplasm, by site, malignant."

If you find the entry for "breast" in the neoplasm table, you will notice that the codes are further differentiated according to the exact area of the breast and the type of malignancy. Because the surgeon removed the sample from the lower-inner quadrant and the pathology report verifies primary malignancy, you should choose 174.3 (Malignant neoplasm of female breast; lower-inner quadrant).

"Skin" lesions require special consideration: For neoplasms that occur on or near the skin of an anatomic site, you should assign a diagnosis for skin - not for the body area in question. For example, if the physician removes a lesion from the skin of a woman's breast that pathology determines is benign, you should report 216.5 (Benign neoplasm of skin; skin of trunk, except scrotum).

Always check the tabular list: In all cases, before assigning a final code, verify the diagnosis you have selected in the tabular index, Jandroep advises.