Part B Insider (Multispecialty) Coding Alert

Published on Mon Sep 15, 2014 PDF

Question: Our physician is treating a patient for lung cancer. The patient has no brain malignancy and was administered prophylactic treatment for the brain. This was previously reported as brain cancer. Is this correct? What are the correct codes for the brain treatment when the patient actually is receiving only prophylactic therapy?

Answer: It is incorrect to report the brain malignancy in this situation. The brain cancer potential as a secondary malignancy to lung cancer cannot be reported as an assumption.

In diagnosis coding issues like this, you should report diagnosis code 162.X (Malignant neoplasm of trachea bronchus and lung) for the ongoing treatment to the lung for lung cancer, with a fourth digit (162.0-162.9) that specifies the location in the lung. Make sure that you code the diagnosis to the highest degree of specificity, i.e., the exact location within the lung the physician is treating.

You may face a challenge when requesting reimbursement for prophylactic treatments. As a general rule, payers provide payment for the treatment of malignancies with radiation therapy. Malignancy is defined as behavior of a life-threatening manner, which includes diagnoses in addition to cancer but does not necessarily include prophylactic treatment. Based on the narrative of the case described, you most likely have not demonstrated this kind of necessity for the brain treatment.

Although a specific ICD-9-CM code exists for prophylactic chemotherapy (V07.31, Need for prophylactic fluoride administration), the code for prophylactic radiation therapy would be assigned to V07.8 (Other specified prophylactic or treatment measure). A secondary diagnosis of V58.0 (Radiotherapy) would be appropriate. The diagnosis of primary lung cancer is the tertiary diagnosis for this treatment.

As authoritative guidance, the American Hospital Association, the entity responsible for maintaining the ICD-9-CM, publishes physician and outpatient coding guidelines. Relevant guidelines that apply to this situation include the following:

• List first the code for the diagnosis, condition, problem or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided.

• List additional codes that describe coexisting conditions. Code all documented conditions that coexist at the time of the encounter and require or affect patient care, treatment or management.

• When coding physician or outpatient services, do not code diagnoses listed as probable, suspected, rule out, questionable or working diagnosis. V codes are assigned when circumstances other than a disease or injury are recorded as diagnoses or problems.