Building a Foundation for Inpatient Coding of Neoplasm

Cathie Wilde, RHIA, CCS - Director, Coding Services Inpatient Coding Leave a Comment

Building a Foundation for Inpatient Coding of Neoplasm

February is National Cancer Prevention Month which promotes taking personal action to lower your risks for cancer. These include making healthy lifestyle choices for diet, exercise, avoiding tobacco products, protection against the sun as well as getting recommended cancer screenings and vaccinating against certain viruses that can cause cancer (e.g., human papillomavirus – HPV). According to the American Cancer Society, 1 in 3 people will be diagnosed with cancer in their lifetime. In 2021, it is estimated there will be 1.9 million new cancer cases diagnosed with 608,570 cancer deaths in the United States. Given these harsh statistics, the coding of neoplasms will be prevalent in our daily coding lives. As such, discussion below will address the fundamentals of neoplasm coding to reinforce competence and accuracy.

The first axis for neoplasm classification is behavior with the second axis, the anatomical site. The five behavior groups are:

Malignant – abnormal tumor cells that extend beyond the primary site, attaching to adjacent structures or spread to distant sites

Neuroendocrine – tumors that arise from endocrine cells; a carcinoid tumor develops specifically from enterochromaffin cells that produce hormones and can be malignant, metastatic or benign (Coding Clinic 4Q 2008, p. 85-90 and 3Q 2019, p. 7-8)

Benign – tumors that are not invasive nor spread to adjacent structures or distant sites

Carcinoma in situ – tumor cells that are undergoing malignant changes but are confined to point of origin and haven’t spread to adjacent tissue

Uncertain behavior – at the time of diagnosis, the exact behavior of the neoplasm cannot be determined, no solid distinction can be made whether it is benign or malignant

Unspecified behavior – neoplasm in which the specific behavior is not specified in the formal diagnosis provided or elsewhere in the medical record. Typically for inpatients, documentation regarding behavior should be documented in the record.

Morphology is the classification of neoplasms by its tissue of origin and focuses on the histopathology of the cells. It is important for use in determining the rate of neoplastic growth, severity of the illness and treatment options. Typically, if the diagnostic statement references the morphology type the coder should first consult the Alphabetic Index under main term, then review subentries. And always verify the resulting code from the Alphabetic Index search in the Tabular List.

Diagnostic statement of liver sarcoma: search main term - sarcoma and subentry -liver results in code C22.4

However, guidance in the Alphabetic Index can be overridden if a descriptor in the diagnostic statement indicates the behavior of the neoplasm. Then the coder is referred directly to the Neoplasm Table to determine the appropriate code.

Diagnostic statement of benign liver tumor: referencing Neoplasm Table for liver, benign establishes code D13.4.

ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.2. outlines detailed guidance in the coding of neoplasms. The basic concept of principal diagnosis applies to the coding of neoplasms but with additional direction provided in the guidelines. Principal diagnosis is that condition established after study to be chiefly responsible for occasioning the admission. In addition to identifying the condition/reason that occasioned the patient’s presentation, the focus of treatment rendered during the hospitalization can serve as a guide as to the appropriate principal diagnosis. Highlights of the guidelines and related AHA Coding Clinic advice include:

If the patient is admitted solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy, assign the appropriate Z51.- code as principal diagnosis followed by the diagnosis code for the neoplasm being treated.

If the patient is admitted for the insertion or implantation of a radioactive elements, the malignancy code is sequenced as the principal diagnosis and the Z51.0 code would not be assigned.

A patient admitted specifically for insertion of a port for later chemotherapy with no chemotherapy administered during the same hospitalization, the neoplasm is designated as the principal diagnosis.

However, if insertion of the port and administration of chemotherapy are done during the same episode of care, Z51.11 is assigned as the principal diagnosis followed by the malignancy as a secondary diagnosis.

When treatment is directed at the primary malignancy, the malignancy is designated as the principal diagnosis.

If the patient is admitted for treatment directed at the secondary (metastatic) site only, then the secondary neoplasm is assigned as the principal diagnosis.

When a patient is admitted for treatment of a non-neoplastic condition in which the pathology report reveals a microscopic focus of malignancy, the principal diagnosis would still be assigned to the condition that originally brought the patient to the hospital for treatment. A common scenario is a male with benign prostatic hypertrophy (BPH) causing urinary retention admitted for a transurethral resection of prostate and the final pathology report finds a microscopic focus of carcinoma. N40.1 would be assigned as the principal diagnosis with CA of prostate, C61 and urinary retention, R33.8 as secondary diagnoses.

When the patient is admitted primarily for the treatment of a complication of the malignancy or the cancer therapy itself, that complication would be assigned as the principal diagnosis. However, there is one exception to this rule – anemia. If the patient is admitted for anemia associated with the malignancy and treatment is rendered only for the anemia, then the associated neoplasm would be assigned as the principal diagnosis followed by the code for the appropriate anemia.

When the patient is admitted for management of anemia associated with the adverse effect of chemotherapy, immunotherapy or radiation therapy, the principal diagnosis would be the anemia.

If the patient presents for management of dehydration due to the malignancy and only the dehydration is being treated, the dehydration would be sequenced as the principal diagnosis.

For patients with an intestinal obstruction due a neoplasm, Coding Clinic indicated that the cancer code would be coded rather than the obstruction code due to direction provided by the Excludes 1 note present at K56.60- and K56.69- (Coding Clinic 2Q 2017, p. 12) FY 2021 has brought a change to the Excludes 1 note (intestinal obstruction due to specified condition – code to condition) in that it no longer applies to subcategory K56.60- (unspecified intestinal obstruction) but continues to apply to subcategory K56.69- (other intestinal obstruction). This is presumably because the diagnostic statement of intestinal obstruction due to a neoplasm would be considered “other” rather than “unspecified” obstruction. Therefore, a patient presenting for intestinal obstruction due to peritoneal carcinomatosis would still be coded to the peritoneal carcinomatosis (C78.6) rather than the obstruction code.

If the patient is primarily admitted for determining the extent of the malignancy or for a procedure such as a paracentesis or thoracentesis, the appropriate malignancy whether primary or secondary based on reason for admission/work up rendered would be sequenced as the principal diagnosis.

When the patient is admitted for a symptom, sign or abnormal finding listed in Chapter 18 which is associated with a neoplasm, the associated primary or secondary malignancy would be sequenced as principal diagnosis rather than the Chapter 18 code.

Section I.C.6. addresses sequencing when the patient has neoplasm related pain – G89.3. This code is assigned as principal diagnosis when the patient is primarily admitted for pain control/management related to the neoplasm. G89.3 may be used as a secondary diagnosis if patient admitted for other than pain control.

The sequencing of the principal diagnosis for patients with pathological fracture due to a neoplasm is dependent on the focus of treatment. If the focus of treatment is related to the fracture, then a code from M48.5- would be sequenced first. However, if the focus of care is for the neoplasm, the malignancy would be the principal diagnosis followed by the pathological fracture code.

A patient admitted for malignant neoplasm associated with a transplanted organ is coded to transplant complication (T86.-) as the principal diagnosis followed by a code for the neoplasm.

If a pregnant patient has a malignant neoplasm, a code from O9A.1- would be sequenced first followed by the specific malignancy code.

Malignant pleural effusion can not only be caused by direct tumor invasion into the pleura (C78.2) but also due to blocked pleural lymphatic drainage from a mediastinal tumor such as can be found in lymphomas. When the malignant pleural effusion is due to impaired drainage, the malignancy is assigned as principal diagnosis followed by the malignant pleural effusion, J91.0.

Sometimes a cancer can result in a tumor thrombus. This is not your usual local blood clot but rather invasion of the tumor into a vessel, typically a vein. It is often seen in the renal or portal veins and would be coded to metastatic site (e.g., vein – C79.89) rather than as a thrombus (e.g., portal vein – I81). (Coding Clinic 2Q 2005, p. 4-5)

Coding Clinic (2Q 2010, p. 7-8, 2Q 2012, p. 9, 1Q 2014 p. 11-13) states a completed cancer staging form authenticated by the attending physician may be used for coding purposes. This tool may be particularly useful for the assignment of secondary malignancies.

Lymphomas are considered systemic diseases and would not be coded to metastatic sites as they do not metastasize in the same way that solid tumors do. Lymphoma patients who are in remission are still considered to have lymphoma and would be assigned to the lymphoma code rather than a history code.(Coding Clinic 2Q 1992, p. 3-4)

Malignancies are coded to a personal history code, Z85.-when the primary malignancy has been previously excised or eradicated and the patient is no longer receiving any treatment to the neoplasm and there is no evidence of existing malignancy at the site.

Code range Z85.0-Z85.85 are to be assigned only for person histories of primary malignancies. To report personal history of a secondary malignancy, assign code Z85.89. Z85.89 may also be reported for personal history of primary malignancy not elsewhere classified.

The current COVD-19 pandemic has had implications in the cancer community with delays in diagnosis and treatment, difficulties in accessing health care services, and economic hardship in obtaining care. This will undoubtedly result in a surge in neoplasm related health care and treatment once the pandemic subsides with likely presentation of patients with more advanced disease.

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