Wiki How to Code Cancer if it is unknown if the cancer is a Primary or Secondary site.

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msumner0314

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Hello,

I work in an orthopedic office and sometimes we see patients for orthopedic injuries that are also currently undergoing treatment for a cancer. 9/10 times the documentation does not specify if the cancer is a primary or secondary site. I'm curious how I go about coding the cancer if I don't have this information. Can I even code the cancer without that info? My fellow employee and myself have combed through the ICD-10 guidelines on this and are having trouble finding anything that gives us a definite answer. Hoping someone can help. I have copied a provider note as an example. :)

4305.

Thank you
Meghan Sumner CPC
 
I would not code the lung cancer in this scenario. You are not treating the lung cancer; it does not even appear you know what type of treatment (IV chemo/ oral chemo/ RT) she is getting. If there was additional information in the note that her lung cancer treatment affected her possible ortho treatment, it would then be appropriate to code. I think it would be safe to assume here "lung cancer" means primary lung cancer. If it said she has lung and brain cancer for example, it would not be clear whether she has 2 primaries; lung metastasized to brain; or brain metastasized to lung.
I only code diagnoses my physician is treating, or if it affects the problem we are treating. Otherwise, you could go down a rabbit hole and code 23 diagnoses for some of your patients.
 
Thank you so much for your response! Yes that makes sense, my brain was thinking that maybe the chemo would affect the healing process for the ortho problem but you are right I can't code it unless the doctor mentions that is is affecting it :)
 
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