Question Oncology in-patient diagnosis coding

Deonne

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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!
 

marandee

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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
 
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