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Wiki need help w/ Ca code

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lisammy

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I have a pt who has adenocarcinoma of the upper lobe. The mass invades the pericardium. Would you code that as 162.3 and 198.89, or 162.8 and 164.1. Any assistance would be helpful. Thanks
 
Invasion generally indicates metastasis; however, depending on your processes, you should query the provider and review the pathology to determine if there are 2 primary sites, or if the pericardium is the acutal mets. This generally works for the inpatient setting rather well, where as in the outpatient setting you may be limited.

If documentation is not clear, or you are not able to query the provider, I would venture to say that lung primary and pericardium mets would be a safe bet.
 
Code neoplasms according to their point of origin which in this case is the upper lobe 162.3. Then code the site of "invasion" or "extension" which in this case is the pericardium 198.89.
 
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