Coding corner update: Improve medical record documentation for neoplasm

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.

Neoplasms should be properly documented in the medical record to support the ICD-10-CM diagnosis code selected.

Neoplasm codes are located in chapter two (codes C00-D49) of the ICD-10-CM manual.

Common neoplasm terms include:

• Malignant includes primary, secondary and in situ. Malignant neoplasms can extend beyond the primary site, they can attach 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 is non-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. These codes are reserved only for times when a diagnosis cannot be substantiated after pathologic examination.

In order to properly code a 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 of the ICD-10-CM manual, there is a neoplasm table. This should be referenced first when choosing a code. However, coding guideline I.C.2. states “if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate”. In this instance, refer to the term (example adenoma) in the Alphabetical Index to review the entries under this term, as well as the instructional note — “see also neoplasm, by site, benign” — under the term. After locating the code in the Neoplasm table, the Tabular List 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 neoplasms

• 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 levels and administers an LHRH drug, you would code C61 — 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 C78.01 – Secondary malignant neoplasm of right lung as the principal diagnosis because that’s what’s being treated. The secondary diagnosis would be C18.6 – Malignant neoplasm of descending colon 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 a code from category Z51 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 Z51.0 – Encounter for antineoplastic radiation therapy first, followed by C50.411 – Malignant neoplasm of upper-outer quadrant of right female breast.

• When coding a malignancy with a complication and management is directed only at the complication, the coding rules vary. Please refer to the Coding Guidelines I.C.2.c.
• An encounter for management of anemia due to sigmoid colon cancer, and the treatment is only for the anemia, the principal/first listed diagnosis code would be C18.7 Malignant neoplasm of sigmoid colon and D63.0 – Anemia in neoplastic disease as the secondary diagnosis.
• An admission/encounter for management of dehydration due to the malignancy and only the dehydration is being treated, sequences the dehydration first followed by the code(s) for the malignancy.

• 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 Z85 (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 Z85.3 – 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-10-CM coding conventions, an additional code should be reported to identify the estrogen receptor status (Z17.0, Z17.1).

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-10-CM Coding Guidelines (Chapter Two: Neoplasms, codes (C00-D49), as well as any instructional notes under the codes in the tabular list of the ICD-10-CM manual, in order to select the correct code, review the additional codes required and find sequencing information.

ICD-10 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.