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Best way to code an invasive and in situ breast carcinoma

  1. #1
    Default Best way to code an invasive and in situ breast carcinoma
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    Hi all!
    I'd like to get some other pathology coders opinions on this scenario - In the past, I was told the proper way to code a case like this would be to only use the invasive carcinoma but we've had a little shakeup in the way we code so now I'd like to get a 2nd opinion. Would just coding the invasive be the best or would you code both for the invasive and in situ breast?

    Right breast, 11:00, 3 cm from nipple, ultrasound-guided core biopsy:
    - Invasive carcinoma.
    - Histologic type: Ductal with micropapillary component
    - Estimated Grade: 23
    - Greatest Length in a Single Core: 9 mm
    - Small focus of ductal carcinoma in situ, intermediate nuclear grade, cribriform type with focal necrosis and microcalcifications.

  2. #2
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    due to the exclude 1 note you do not code the C50 code with the D05 code so code only the invasive. you could code both and use the exclude 1 exception if documentation were to indicate invasive in one breast and in-situ in the other.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    Thank you! I didn't even think to look at the back for the excludes (I have to admit, I'm a little lazy and I rely on my billing department to let me know if something has been kicked or not for an excludes as I have tons of coding to do a day and not enough time to check each of them lol) - and thank you also for giving me a heads up about the left and right breast invasive and in situ - I have made a notation and will let my department know if a case like that should come up.

  4. Default
    Quote Originally Posted by mitchellde View Post
    due to the exclude 1 note you do not code the C50 code with the D05 code so code only the invasive. you could code both and use the exclude 1 exception if documentation were to indicate invasive in one breast and in-situ in the other.
    If I can ask a follow up question to this...
    So then do the conditions that are listed in the Excludes 1 notes NOT matter? I'm asking because the Excludes 1 note on D05 specifically states that it excludes "Paget's disease of breast and nipple (C50._)". Invasive carcinoma and Paget's disease are NOT the same things.
    And if these conditions don't matter, why are they even listed?
    This question has come up in our coding as well (and actually with these specific codes), so I'm trying to figure out a definitive answer to this.
    Thank you!

  5. #5
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    Pagets disease of the breast is invasive carcinoma of the central portion of the breast. If you look it up in the index under pagets and then breast the index takes you to the C50.1 code series. And look up the definition of pagets of the breast and you get the same answer. The exclude one note while the description states pagets of the breast the code reference is for all C50 codes.

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    It's true that Paget's disease involves the nipple (and areola), but I don't think we can say that it's the same as invasive carcinoma just of a specific area. Also, here is something from Mayo Clinic, "Most women with Paget's disease of the breast have underlying ductal breast cancer, either in situ meaning in its original place or, less commonly, invasive breast cancer." And that would explain why there is an Excludes 1 under D05 that specifically lists Paget's disease -- these two conditions are oftentimes seen together -- one goes with the other.
    This is not the case for other invasive carcinomas of the breast, is it? Meaning, the presence of an invasive carcinoma doesn't necessarily mean, there is a ductal (or lobular) carcinoma in situ.
    My suspicion is, if these conditions under Excludes 1 notes didn't matter, why list them at all? Why did they go through the trouble of listing these specific conditions and didn't just simply list the code? Do you see what I mean?
    I wish there were a way to get a definitive answer regarding interpretation of these Excludes 1 notes. As it is right now, the guidelines are not very clear.

  7. Default AAPC monthly magazines
    Quote Originally Posted by mitchellde View Post
    due to the exclude 1 note you do not code the C50 code with the D05 code so code only the invasive. you could code both and use the exclude 1 exception if documentation were to indicate invasive in one breast and in-situ in the other.
    I was just taking about a similar scenerario with my friend, one of the monthly magazines, has a question(#12, I kept the question #, but nothe the month of the magazine ) left breast invasive and ductal carcinoma in situ, and all the answer available have both ICD diagnosis C50.512, D05.12. Can you help me understand, why not just the invasive carcinoma C50.512?

    Thank you all for your time
    Last edited by dcruz; 10-23-2018 at 03:40 PM.

  8. #8
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    Hi Olga,

    I'll throw my two cents in here, I guess. Maybe it'll help?

    I see path notes for breast cancer all the time where my path's are documenting both invasive malignant carcinoma and DCIS and/or lobular CIS found in the same breast. So I say, yes, a breast specimen can have more than one type of cancer present at the same time. If you think about how dense the mammary tissue is with the ducts, glands and fat, it makes sense actually that it could have small pockets of cancer in different stages spread throughout it. The excludes notes are letting us know NOT to code for both at the same time (on the same breast). The invasive malignant carcinoma takes precedence and is the one to code for. By location/laterality of course.

    Here's a portion of the definition of Paget's breast from the SEER manual on NIH/NCI...
    "Paget Disease: Paget disease of the nipple is a condition where the epidermis of the nipple is infiltrated with neoplastic cells. ICD-O-3 classifies all mammary Paget disease as a malignant process with a malignant behavior (/3)." (ICD-O refers to the oncology version)

    So that's telling us that Paget's disease of the breast is always considered malignant, hence it's classification in ICD-10-CM to codes under the C50.- tree (the SEER codes C500 and C501 are specific to their ICD-O-3 version, but are intended to match up to ICD-10 in most codes).

    I like the coding guidelines on their site as well, really helped me with understanding how to assign a specimen to the correct location based on the language used in the path report. Attaching a copy as some may also find it helpful. HOWEVER - keep in mind, this is only a useful tool. It's a coding guideline for the SEER program for doctors, not necessarily one for us. But understanding the terms and definitions can be helpful in abstracting the clinical data into something understandable to a coder's daily work.

    HTH
    Attached Files Attached Files
    Last edited by Sundancer; 10-23-2018 at 04:40 PM. Reason: clarity
    Laurie S Lemons, CPC

    Coder I, Surgical Pathology
    Inova Health Systems

    2019 President
    2018 Past Education Officer/VP
    2015-16 Past President
    AAPC Woodbridge, VA chapter

  9. #9
    Default coding C50.xx with D05.xx
    Hi fellow pathology colleagues,

    Would you please help, I have questions on this post. Oh goodness would someone be able to help please explain?

    I saw that "due to the exclude 1 note you do not code the C50 code with the D05 code" - where is this exactly stated for the coder to abide by these rules?
    Somehow did CMS roll out something I am not aware of?
    I am a solid book coder (no I do not utilize 3M or any other software) so I would appreciate any information on this please to ensure I am coding my pathology reports correctly.

    I pulled my ICD-10-CM for 2016, 2017 and 2018.

    I have the ICD-10-CM 2018 from AHIMA that Rasmussen College provided me and reviewing C50 it simply states to code "use additional code to identify estrogen receptor status (Z17.0, Z17.1)". The only thing that C50 excludes is C44.01, C54.511, C44.521, C44.591

    So I grabbed my ICD-10-CM for 2017 the Expert edition for Expert for Physicians and C50 states to use additional code to identify estrogen receptor status (Z17.0, Z17.1) and the Excludes 1 state "skin of breast" (C44.501, C44.511, CC44.521, C44.951)

    For 2016 AAPC book from the AAPC. I turned to C50.xx and it states "use additional code to identify estroggaen receptor status (Z17.0, Z17.1)". The only thing that C50 excludes is C44.01, C54.511, C44.521, C44.591

    So if someone could simply explain the exclude 1 coding breast ductal or lobular carcinoma in situ (codes D05.xx), I would be very appreciative.

    I appreciate your time on this matter, this would be important for goodness all the pathology reports I review.
    Once again thank you all for listening to me and again any help you can offer is very appreciated!
    Thanks,
    Dana

  10. #10
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    If you look in the ICD-10 2019 book, on page 493 under "D05" (carcinoma in situ breast) - you'll see the excludes 1 note that states you can't use "C50" with it. Why they don't include this same excludes under the "C50" code is a mystery to me since they can't be used together (or if it is there, like you, I can't see it either) but I guess it's not for me to ask lol - I hope this helped!
    Last edited by Shekendan; 10-30-2018 at 10:20 AM.

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