NEOPLASM DIAGNOSIS CODING AND SEQUENCING Diana R Phelps, CPC, CPC-I, CEMC Approved AAPC ICD-10-CM Instructor

OBJECTIVES Guideline information Neoplasm Treatment directed at malignancy or secondary site Sequencing of neoplasm code, complications Chemotherapy, Radiotherapy, or Immunotherapy Symptoms, signs and abnormal findings Pregnancy with malignancy Transplanted organ with neoplasm complication

ICD-10-CM Manual Review for 2019 Tabular Review Note significant guidelines updated 45 New codes for Neoplasm Use of green text (some books) Manifestation codes (blue color bar) Sequencing of Tabular codes C43 to C4A to C44 C75 to C7A to C7B to C76 Use of 7th character Colors meaning: “No” X-placeholder “Yes” use X (s) as placeholder

EXCLUDES 1 EXCLUDES 1 note is a pure excludes. It means “NOT CODED HERE!” An EXCLUDES 1 note indicates mutually exclusive codes: two conditions that the code excluded should never be used at the same time as the code above the Excludes 1 note. An EXCLUDES 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Example: C00 Malignant neoplasm of lip EXCLUDES 1: malignant melanoma of lip (C43.0) Merkel cell carcinoma of lip (C4A.0) other and unspecified malignant neoplasm of skin of lip (C44.0-) See next slide

EXCLUDES 2 Example: C05.1 Malignant neoplasm of soft palate EXCLUDES 2 note represents “NOT INCLUDED HERE” An EXCLUDES 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an EXLUDES 2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. Example: C05.1 Malignant neoplasm of soft palate EXCLUDES 2: malignant neoplasm of nasopharyngeal surface of soft palate (C11.3)

INCLUDES AND USE ADDITIONAL CODE C03 Malignant neoplasm of gum Includes: Malignant neoplasm of alveolar (ridge) mucosa Malignant neoplasm of gingiva Use additional code to identify: alcohol abuse and dependence (F10.-) history of tobacco dependence (Z87.891) tobacco dependence (F17.-) tobacco use (Z72.0)

“CODE ALSO”NOTE A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. C25 Malignant neoplasm of pancreas Code also exocrine pancreatic insufficiency (K86.81) Use additional code to identify: Alcohol abuse and dependence (F10.-)

NEOPLASMS (C00-D49) NOTE Functional activity Morphology (Histology) An additional code from Chapter 4 may be used Morphology (Histology) Primary malignant neoplasms overlapping site boundaries Malignant neoplasm of ectopic tissue

MALIGNANT NEOSPLASM (C00-C96) TIP Codes from this code block can be assigned based on the diagnosis listed in a pathology or cytology report when authenticated by a pathologist and available at the time of code assignment.

CODE THESE: A 28 year old is treated for melanoma of the left breast and left arm. Subacute monocytic leukemia in remission. Burkitt’s lymphoma of intrapelvic lymph nodes. Endometrial sarcoma.

NEOPLASMS (C00-D49) Distinguish the type of Neoplasm Malignant Primary Malignant Secondary Ca in situ Benign Uncertain Unspecified

NEOPLASM TABLE

NEOPLASMS (C00-D49) Treatment directed at malignancy or secondary site Treatment at primary site Treatment at secondary site How do you code these?

NEOPLASMS (C00-D49) Guidelines chapter 2 Treatment directed at the malignancy It the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. Only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy, assign the appropriate Z51.- code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

NEOPLASMS (C00-D49) b. Treatment of secondary site When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. The neoplasm table may be used to find the code, but always verify them in the tabular list as well, especially for the additional characters.

CODE THESE Carcinoma of mid-esophagus which spread to celiac lymph nodes. Patient came in for a check up on metastatic lung cancer due to breast cancer.

CODE THIS The encounter is to receive chemotherapy following the recent diagnosis of carcinoma of the small intestines. The tumor was in the area where the duodenum and jejunum join. The cancer was resected two months ago and the patient has been receiving chemotherapy.

NEOPLASMS (C00-D49) Encounter is to diagnosis malignancy Assign a code for sign(s) symptom(s) until confirmation of the diagnosis is made. Some neoplasms are functionally active in that them may affect the activity of endocrine glands. Code for the primary neoplasm first, followed by an additional code (code also). Example: C56.0 + E28.0 Hyperestrogenism due to carcinoma of right ovary.

NEOPLASMS (C00-D49) Anemia Admission/encounter is for management of anemia associated with the malignancy, and treatment is only for anemia Code the malignancy first Then code D63.0 Anemia in neoplastic disease Admission/encounter is for management of an anemia associated with adverse effect of the administration of chemotherapy or immunotherapy Code anemia first Followed by the appropriate code for the neoplasm Then the adverse effect (T45.1X5-)

NEOPLASMS (C00-D49) Anemia Admission/encounter is for management of an anemia associated with adverse effect of radiotherapy Anemia code should be sequenced first Followed by the appropriate code for the neoplasm Then code Y84.2, Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.

CODE THESE A patient with metastatic non-small cell lung cancer of the right upper lobe develops anemia following chemotherapy. The patient presents to her oncologist for treatment of anemia due to chemo. The encounter is for management of an anemia associated with an adverse effect of radiotherapy.

NEOPLASMS (C00-D49) Dehydration or a Complication Admission/encounter is for dehydration or a complication due to malignancy Code dehydration or complication first Followed by malignancy code Example: Patient with pancreatic cancer is seen for initiation of TPN for cancer-related moderate protein-calorie malnutrition E44. 0 + C25.9

NEOPLASMS (C00-D49) Pregnancy Pregnant woman has a malignant neoplasm Code from subcategory O9A.1- should be sequenced first Followed by the appropriate malignancy code Exception is in an incidental condition

NEOPLASMS (C00-D49) Pathological fracture Encounter for Pathological fracture Code from M84.5- should be sequenced first Followed by the code for the neoplasm If the focus is the neoplasm with pathological fracture Code neoplasm first Followed by M84.5-

NEOPLASMS (C00-D49) Transplanted organ Encounter for malignant neoplasm of a transplanted organ should be coded as a transplant complication. Code from category T86.- complication of transplanted organ Followed by code C80.2, malignant neoplasm associated with transplanted organ Use additional code for the specific malignancy

CODE THESE: Female 36 years old in 2nd trimester comes to the office for routine follow up due to ovary carcinoma. A 76 year old male comes in to ER due to a right femur pathological fracture when he got out of bed today, he also has metastatic bone cancer. 53 year old male had a liver transplant 5 years ago and now comes in due to cancer in the liver.

QUESTIONS