Coding corner update: Improve medical record documentation for leukemia

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next few issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Leukemia is cancer of the white blood cells that will affect an estimated 54,270 new patients in 2015 alone, according to the American Cancer Society. A basic understanding of this neoplastic disorder will help with coding and documentation accuracy. The body is constantly producing new blood cells to stay healthy. Blood cells are produced by blood stem cells found within bone marrow and occasionally the blood itself.

Blood stem cells produce three specific types of blood cells: red blood cells, platelets and white blood cells. Each blood cell has a unique function within the body, aiding in healing and healthy living. When normal blood cells are old or damaged they die off and new ones are produced.

Leukemia occurs when the bone marrow starts producing abnormal white blood cells known as leukemia cells or leukemia blast cells. The production of the abnormal white blood cells takes over cell production, causing normal blood cell production to be halted. Leukemia cells multiply quickly and don’t die off like normal blood cells. Without the production of normal blood cells the body works harder to get oxygen, control bleeding and fight infections.

The major code categories in ICD-10 for leukemia are as follows:

• C90.1 Plasma cell leukemia
• C91 Lymphoid leukemia
• C92 Myeloid leukemia
• C93 Monocytic leukemia
• C94 Other leukemia of specified cell type
• C95 Leukemia of unspecified cell type

The code categories are further categorized by acute or chronic, specified cell types and whether or not remission had been achieved.

Tips to remember when coding leukemia
Leukemia codes are found throughout the neoplasm chapter and specific types are categorized in sections C90.1 through C95.

• Physicians must clearly document the specific type of leukemia, whether it is acute or chronic and state of remission or relapse.
• Relapse refers to the recurrence of the disease after being successfully treated. A relapse can occur at any time during treatment or after treatment is completed. The provider must clearly document the patient is “in remission” or “in relapse” so the appropriate fifth digit may be assigned.
• 0 — Not having achieved remission (includes failed remission): According to American Hospital Association Coding Clinic fourth quarter, 2008, page 83 through 84, failed remission refers to remission induction therapy where the patient is given a course of chemotherapy to produce a complete remission and the treatment fails.
• 1 — In remission: Currently not showing any signs or symptoms of the disease.
• 2 — In relapse: Signs and symptoms of the disease have reoccurred after being treated successfully.
• Note: These same concepts for the coding of leukemia which include not having achieved remission, in remission and in relapse have been carried over to ICD-10-CM. If the reason for a patient encounter is antineoplastic chemotherapy, report Z51.11 or Z51.12 for encounter for antineoplastic immunotherapy as the primary diagnosis code followed by the correct leukemia code.
• Leukemia is classified in the neoplasm chapter, yet it’s not found within the neoplasm table. In order to accurately code leukemia it must first be located in the alphabetical index, under the correct subcategory. Code verification in the tabular is essential for accurate fifth-digit reporting.

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.