The Coding Sleuth 14
by Tara Conklin
The door to my office flew open and there she stood her hair in complete disarray and a desperate look on her face. I put my pencil down; I’d seen the same look too many times before it was nothing new. “Diagnosis Problems” I asked. Her shoulders dropped and she simply nodded. “These neoplasm codes are just driving me crazy. I don’t know when to code primary when they have secondary and what if cancer is unconfirmed. It’s all just so very confusing. Please help.”
I cleaned off a chair that was covered in papers and offered her a seat “Coffee?”
“Please” she plopped down.
I went to the filing cabinet, pulled out a file labeled “Neoplasms” and returned to my desk. Shoving aside reports, today’s paper, my copy of “Pirates of the Caribbean” DVD, and my ICD-9, I flipped through the file and began to explain.
The first thing to understand with neoplasm codes is they are categorized to the location of the pathology, not the actual cell type of cancer itself. For example if the patient has a Small Cell cancer that started in the lungs but has moved to the liver, you wouldn’t code treatment of the liver as “primary lung cancer”. It may be the type of cancer you’re treating but it’s the site that matters. Some Chemotherapy medications are designed to treat cancers in particular organs so the code applied should be designated to the actual location of the disease being currently treated. Physicians and clinicians have a tendency to look at neoplasm coding from the pathological standpoint and want to pick the code based on the actual type of cancer they are treating.
Once we establish the location of the cancer we need to determine what kind of cancer we are dealing with. I’m not talking about the specific name of the cancer like those found in the Morphology codes in the back of the ICD-9. Those are not used for outpatient or physician claims. They are only used by hospitals and other facilities. What I’m talking about is the cancers’ relation to the particular site it occupies. Did it start there or did it decide it didn’t like the neighborhood so it packed up its bags and moved somewhere else. Or perhaps it thinks it Donald Trump and is setting up shop in several locations, pulling a type of Monopoly, (I never did get my shot at Park Place). Regardless of whether or not the cancer is a homebody, a nomad or Donald Trump establishing its “personality” is the first step.
Looking at the neoplasm table in the ICD-9 (which got a whole lot smaller this year) we see the codes are categorized by “primary, secondary, ca in situ, benign, uncertain behavior or unspecified.” We’ll consider these the “multiple personalities of neoplasm.”
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Let’s say neoplasms are a kin to pirates, the first two types of neoplasm are malignant or cancerous so they resemble our rouge outlaw pirates. Primary neoplasm is the place it originally showed up in kind of like its Home Port. Some cancers choose to occupy more than one location and will set up show in several |
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other ports. These additional ports of call are our secondary neoplasm, commonly referred to as “metastatic”. Even if the pirates at home port are defeated, if they still have rouge associates at any of these additional locations, these are still considered “secondary” and should be classified as such. Now Ca in situ or carcinoma in situ (site being a Latin phrase meaning “in place”) is a different problem. This is not really cancer or a full blown outlaw just yet. It may sound like it but it is considered a pre-cancerous problem. It’s like someone who dresses like a pirate, and talks like a pirate and acts like a pirate, but hasn’t joined the ranks of pirates just yet. Also, like the meaning of “situ” states, hasn’t gone anywhere yet. It’s just staying put in one place. |
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Now believe it or not, not all pirates were bad. Some were actually hired by the governments to go after the outlaw pirates and steel back from them the treasures they took. These were the Buccaneers and although scary and ferocious in their own right were actually pretty harmless to the average law abiding citizens. It’s safe to say they were “benign”. This is exactly what benign neoplasm’s are like. They look scary but don’t offer any real threat.
The last two pose a problem for coders. Neoplasms with “uncertain behaviors” are when at the time of coding, the physician is just not sure exactly what he is dealing with. He needs to take our pirate to the pub (pathology) and given him a few drinks so to speak, see if he can get him to talk. Only when a neoplasm has been clearly identified as either cancerous or benign should it be classified to one of the first four categories. Unspecified is the biggest problem, because that’s when our good doctor simply isn’t telling us what kind of pirate we’re dealing with. We don’t know if he should be hunted down for crimes or just kicked out of town for scaring us to death. When dealing with a lesion excision or biopsy, clarification from the doctor should always be obtained before coding the service. If the type of neoplasm is not clear at the time of biopsy or excision you should always hold the ticket before coding to make sure you not only have the right diagnosis, but can also append the correct procedure code. As we known lesion removal codes are categorized by benign or malignant; much like our pirates. If the documentation only offers the specific name of the neoplasm and you are not sure which code to classify it to, the morphology codes in the back of the ICD-9 offer an easy way to figure it out. For example if the report states “Basiloid Carcinoma” and nothing else. In the alphabetic index under “carcinoma” we find “basaloid” listed as M8123/3. Turning to our Appendix A: Morphology listing, we notice the codes are in numerical order. Looking down we find the code listed under M809-811 Basal cell neoplasm. The part before the (/) is only the classification code, it’s the number after the (/) we want to concern ourselves with. In the beginning of this appendix definitions to this last number are provided with 0=benign, 1-uncertain whether benign or malignant borderline malignancy, 2-carcinoma in situ, 3-malignant primary, 6-malignant metastatic or secondary, 9-malignant uncertain whether primary or metastatic site. With this information we can quickly deduce that the 3 in our Basaloid Carcinoma classified it as a primary malignant cancer. We wouldn’t use this code on our physicians’ claim but it’s a helpful tool to gleam the information we need.
So now we have a good understanding of what the different types of neoplasm mean how do we know which one to use for each service? If you remember your coding rules, you should remember that the primary diagnosis should always reflect the service provided or the reason for the visit.
Let’s say we have a patient with primary liver cancer which has migrated to the lungs. Today’s visit is focused on treating the lung cancer. Since the treatment, medication and work involved is geared toward the lung cancer the code for secondary neoplasm of the lung 197.0 should be our primary diagnosis. Primary liver neoplasm could be used as secondary along with any manifestations of the cancer.
If our treatment is for agranulocytosis or a decrease in white blood cells associated with neoplasm and chemotherapy treatments, our primary diagnosis would be 288.0 followed by the appropriate neoplasm code. The rule of thumb in all coding is to code to the reason for the visit.
Two last things to remember with neoplasm; in your neoplasm table you will see several codes listed with asterisks (*) next to them. The guidelines at the beginning of the neoplasm table state “sites marked with the sign * should be classified to malignant neoplasm of skin or these sites if the variety of neoplasm is a squamous cell carcinoma or an epidermoid carcinoma, and to benign neoplasm of skin of these sites if the variety of neoplasm is a papilloma.
Lastly, the term “mass” is not synonymous with neoplasm, as it is often used to describe cysts and thickenings such as those occurring with hematoma or infection. When you see the term “mass” don’t assume it’s a neoplasm, report it with the most specific code available specific to that particular body site, or wait for any pathology reports first. The term “mass” is more of a symptom than an actual disease or disorder.
Armed with the right information neoplasm coding is as harmless as Mickey Mouse on the high seas. What’s difficult is trying to figure out who’s better looking as a pirate Johnny Depp or Orlando Bloom… popcorn anyone?
Until next time Coding Sleuths!
--Tara