Keep in mind these tips to improve medical record documentation for neoplasm coding

Neoplasm should be properly documented in the medical record to support the ICD-9-CM diagnosis code selected. 

Neoplasm diagnosis codes are located in chapter two (codes 140-239) of the ICD-9-CM manual; however, there are some benign neoplasms located in the specific body system chapter.

Common neoplasm terms include:

• Malignant includes primary, secondary and "in situ." It extends beyond the primary site, attaches to adjacent structures and can spread:
• Primary is the original site (tissue or organ) where the cancer started.
• Secondary is a cancer that refers either to a second primary cancer or to cancer that has spread from one part of the body to another, also known as metastatic cancer.
• In situ refers to a cancer that has stayed in the place where it began and has not spread to neighboring tissues.
• Benign isn’t invasive and doesn’t spread to adjacent or distant sites.
• Uncertain behavior is behavior that can’t be determined; there’s no distinction between malignant and benign.

In order to properly code neoplasm, it’s necessary to determine from the documentation if the neoplasm is benign, in situ, malignant or of uncertain behavior. Secondary (metastatic) sites should also be determined when malignant neoplasm is involved.

In the Alphabetical Index (Volume 2) of the ICD-9-CM manual, there is a neoplasm table. This should be referenced first when choosing a code. The exception is when the histological term is documented. In this instance, refer to the term in the Alphabetical Index to see the entries, as well as the instructional note — “see also neoplasm, by site, benign” — under the term. After locating the code in the table, the Tabular List (Volume 1) should be referenced to verify the correct code has been selected. Remember to always code to the highest specificity per the documentation.

Some tips to remember when coding neoplasm

• If treatment is directed at the site of the malignancy, the principal or first-listed diagnosis should be the code for the malignancy. 
• For example, if a patient comes in for a recheck of his prostate cancer, and the doctor  reviews his PSA and increases his medication dose, you would code 185 – Malignant neoplasm of prostate.

• When a primary malignancy metastasizes and the treatment is directed at the secondary site, the secondary neoplasm is the principal or first-listed diagnosis. 
• For example, a patient comes in for treatment of lung cancer, which has metastasized from his primary site of colon cancer. In this instance, you would code 162.9 - Malignant neoplasm of bronchus and lung, unspecified as the principal diagnoses because that’s what’s being treated. The secondary diagnosis would be 153.9 - Malignant neoplasm of colon, unspecified site because the treatment for that visit is being directed at the lung cancer.

• If a patient is being seen for the sole purpose of administration of chemotherapy, immunotherapy or radiation therapy, the use of code V58.x should be the principal or first-listed diagnosis. 
• For example, if a patient has breast cancer and she is being seen that day for administration of radiation therapy only, you would code V58.0 – Radiotherapy, first, followed by 174.9 – Breast (female), unspecified.

• When coding a malignancy with a complication and management is directed only at the complication, it would be listed as the principal or first-listed diagnosis and the malignancy would be listed second.
• For example, a physician documents that his patient has anemia associated with colon cancer. The patient is at the office today for treatment of the anemia. The correct sequence for this date of service would be to code 285.22 – Anemia in neoplastic disease as the primary diagnosis, and 153.9 – Malignant neoplasm of colon, unspecified site as the secondary diagnosis.

• If a primary malignancy has been eradicated, there is no current treatment directed at the primary malignancy site and there is no evidence of the primary malignancy, please use a code from category V10 (Personal history of malignant neoplasm).
• If a physician documents “patient diagnosed with breast cancer, 5/2001, surgery. Tamoxifen therapy discontinued 8/2009, no evidence of recurrence of malignancy. Routine yearly mammograms have remained non-eventful.” This would be coded as V10.3 – Personal history of malignant neoplasm; Breast.

Coding breast cancer
According to the American Cancer Society, it was estimated that there would be 297,000 new female breast cancer cases in 2013 (in situ and invasive combined) and 39,600 women were expected to die from breast cancer. Only lung cancer is responsible for more cancer deaths in women, ahead of breast cancer.

Documenting the specific location of the neoplasm is important because there are codes for the various regions of the breast, as well as an unspecified code. Also, per ICD-9-CM guidelines, the physician should always document the estrogen receptor status when a diagnosis of active breast cancer is listed.

Coding colon cancer
Colon cancer is the third most common cancer among men and women. The American Cancer Society estimates that there will be 136,000 new colorectal cancer cases in 2014, with approximately 50,000 of those resulting in death.

As with breast cancer, documenting the specific location of the neoplasm is important because there are codes for the various regions of the colon.

It’s important to review the ICD-9-CM Coding Guidelines (Chapter Two: Neoplasms, codes 140-239), as well as any instructional notes under the codes in the tabular list of the ICD-9-CM manual, in order to select the correct code, review the additional codes required and find sequencing information.

For questions or more information, please contact your provider consultant.