Pulmonology Coding Alert

Question: A patient is undergoing treatment for lung cancer with prophylactic treatment to the brain. I have found from earlier instances that someone had erroneously coded the treatment for brain cancer. Is it correct? There is no current brain cancer, only lung cancer, but there is allied treatment to the brain. How do we correctly code this?

North Dakota Subscriber

Answer: No, coding for brain cancer definitely wrong, as you are reporting a secondary malignancy with the assumption that the brain cancer was coded as secondary to the lung cancer. However, it is clear that no cancer has been diagnosed at the time of treatment.

In diagnosis coding issues like this, you should report a diagnosis code 162.- (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., to the exact location within the lung that the physician is treating.

You may face problems while asking for reimbursement in 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. Your case does not demonstrate this kind of necessity for the brain treatment.

Although a specific ICD-9 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, 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.