Wiki Oncology in-patient diagnosis coding

[Deonne]

I have a patient with a confirmed Melanoma diagnosis and a biopsy confirmed secondary cancer of lymph nodes. The patient had a CT scan that showed a liver mass and pulmonary nodules. The doctor chose ICD10 dx codes of secondary liver and secondary lung cancer but the documentation says "likely" metastatic cancer of lung and liver and will be treating this as cancer unless proven otherwise. No biopsy is ordered to confirm. Should I code the lung and liver as cancer or just masses at this point? Is the CT scan enough for the Dr to code cancer or does it have to be biopsy confirmed? Would really love some input and also any suggestions/recommendations for Oncology/Hematology resources or training, as I am basically teaching myself this specialty. Thanks in advance!

 

[rachaelwilleford]

Per ICD10 Guidelines, Section II - H:
If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out" or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

If it's outpatient, you would follow section IV - H:
Do not code diagnoses documented as "probable", "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

Malignancy doesn't deviate from the ICD 10 coding guidelines. I code it as cancer unless the doctor expresses uncertainty with "likely", "probable", etc. at which time I query the physician and explain to them the guidelines.

 

[marandee]

Not positive because I do not code for Oncology, but my line of thinking: Commonly, liver melanomas are the result of metastasis or the spreading of a malignant melanoma that originated from non-adjacent tissues or organs.
Is it liver melanoma?
Best bet is to query the physician when there is no lab, but physician makes the diagnoses. S/he attests to their findings with signature. Also, he is treating the patient according to his/her cancer diagnosis.
GL