Wiki Kathleen Pina CCS,CPC

[pinakapina]

Hi, Today I had a chart with the patients diagnosis of primary gastric carcinoma with metastisis to the pleura. The radiology report stated a pleural effusion. After thoracentesis the cytology report stated positive for malignant metastisis in the pleural fluid. I am having a hard time deciding whether or not to code malignant pleural effusion or secondary carcinoma of the pleura or both in addition to the primary gastric carcinoma. 511.81 or 197.2 or both??? It kind of sounds redundant to put both.

 

[007CPC]

Hi, Today I had a chart with the patients diagnosis of primary gastric carcinoma with metastisis to the pleura. The radiology report stated a pleural effusion. After thoracentesis the cytology report stated positive for malignant metastisis in the pleural fluid. I am having a hard time deciding whether or not to code malignant pleural effusion or secondary carcinoma of the pleura or both in addition to the primary gastric carcinoma. 511.81 or 197.2 or both??? It kind of sounds redundant to put both.

Since cancer is a more specific condition that was found after study you would code initially cancer in pleura, over pleura effusion. But since malignant pleura effusion is important with identifying stage of cancer, code effusion 3rd.
This may vary depending on what type of coding you do....
You might want to check with contemporary coder for verification.