Wiki Borderline Serous Tumor of ovary

[ELBrock]

Pathology Report: "Ovarian serous borderline tumor. - No gross evidence of extracystic extension of tumor."

Providers choice: D39.11 (Neoplasm of uncertain behavior, right ovary)
My selection: C56.1 (Malignant Neoplasm of right ovary)

I came to my selection by following the ICD-10-CM Index
Term: Tumor
Subterm: Serous - of low malignant potential - see Neoplasm, malignant, by site

I also went under the index term "Cystadenoma"
Subterm: Serous - Borderline Tumor
Ovary - C56
Specified Site NEC - see Neoplasm, uncertain behavior, by site

Am I following the ICD-10-CM index wrong here? Since this is of the ovary, it leads directly to malignancy coding. Any input would be helpful. Thank you!

 

[thomas7331]

Since the pathology report documents neither 'of low malignant potential' nor 'cystadenoma' nor 'borderline malignancy', in my opinion, using any of these pathways to code it as malignant would be incorrect and unsupported. And if the provider, who has the clinical expertise here, is interpreting this pathology as uncertain, then I would defer to their judgment on this. (Incidentally, the index in my edition shows 'borderline malignancy' as the subterm under cystadenoma, serous, not 'borderline tumor').

 

[ELBrock]

Thank you for your reply, thomas7331. From my research online, Ovarian borderline tumors are classified as “of low malignancy potential” tumors. I believe that is why the index has that wording. I will of course follow the providers selection, but am just trying to grasp a better understanding of this “ovarian serous borderline tumor” concept. Thank you for the correction to the wording in the index for cystadenoma. The provider did not select their code until the patients postop visit, so for code selection of the surgery, I’m trying to understand how to get to the code myself.

If I follow the Index term for Tumor, there is no other option under “serous” for anything but “of low malignancy potential.” Unless I ignore the terms “serous” and “borderline,” and just look under ovary, I won’t be led to the same code as the doctor. Looking up the term “serous” online shows it’s a part of the epithelial layer normally occurring in the ovaries. So my thinking is if “Borderline” means it’s of “low malignancy potential” (for the ovaries at least) and it’s of the “serous” cells of the ovary, then my code selection could possible be correct? At least according to ICD-10-cm guidelines?

 

[ELBrock]

I just wanted to share that I found an article on ACOG's site stating that borderline tumors are also called tumors of low malignant potential. To code for borderline tumors, they instruct the coder to the Alphabetic Index for Diseases and look for Sub-term "Serous of low malignant potential" under the Main term "Tumor," instructing to see Neoplasm, Malignant, by site. They also provide the DX codes C56.1 (Malignant neoplasm of right ovary), C56.2 (Malignant neoplasm of left ovary), and C56.9 (Malignant neoplasm of unspecified ovary).

 

[thomas7331]

I think there is always an element of judgment involved in code selection, especially in situations like this. I always say that guidelines are just that - guidelines and not rules or regulations - and there often comes a point where a coder has to make a choice as what in their judgment best represents the record, and be prepared to defend it. Typically, I recommend caution in the use of outside sources and Google searches in the interpretation of terms in the medical records because they may or may not hold up well against audit findings. But if you have a reference to support you from ACOG, a reputable professional society, then that would certainly be a good defense and support for your choice, should you need it. Thanks for sharing that!