The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 5 Coding Neoplasms Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes ·Explain the difference between benign and malignant. ·Identify the various types of neoplasms. ·Determine the proper sequence of coding multiple neoplasms

Learning Outcomes ·Distinguish between primary and secondary malignancies. ·Use morphology codes correctly. ·Apply the guidelines for coding admissions for the treatment of complications

Introduction ·A neoplasm is abnormal tissue growth or a tumor. ·Not all neoplasms are malignant. ·Cancer is the common term for carcinoma or malignancy

Neoplasms Terms used to describe neoplasms include ·adenoma ·melanoma ·leukemia ·papilloma 5 - 5

Neoplasm Table ·Primary [Malignant]: The first anatomical site where malignancy is identified ·Secondary [Malignant]: Second and subsequent anatomical sites to which the malignancy has spread or metastasized 5 - 6

Neoplasm Table ·Ca in situ [Malignant]: Tumor has undergone malignant changes but has not spread. ·Benign: Not cancerous ·Uncertain behavior: Pathologist cannot determine

Neoplasm Table ·Unspecified: The documentation is not complete or specific with regard to the nature of the tumor. This code should be chosen only as a last resort. The physician and/or pathologist should be queried

Functional Activity When a neoplasm might affect the patient’s glandular function, the functional activity of the gland affected must be reported with a separate code

Overlapping Boundaries ·A malignancy without clear or identifiable borders affecting multiple anatomical sites ·Use an “other specified sites” descriptor or “multiple sites.”

Morphology Codes ·M codes listed in alphabetic index and Appendix A ·Not used for reimbursement purposes ·Are NOT placed on UB-04 or CMS-1500 claim forms

Coding Sequences ·When multiple issues are addressed during one visit, list the most severe first. ·If primary malignancy is not addressed at all, list it last, but include it anyway

Excised Malignancies ·Report an excised malignancy with a Personal History of... V code. ·List the V code after any current neoplastic conditions

Prophylactic Removal ·Genetic testing may provide a predictor of malignancy. ·Some patients will opt for removal of a potential malignancy BEFORE getting any signs or symptoms. ·Code this with a V code

Therapies Chemotherapy and Radiation: ·When the only reason for admission to a hospital is chemo or radiation treatment, code this first, followed by neoplasm codes

Complications Treatment of complications: ·Code the complication first, followed by the code for the neoplasm(s)

Chapter Summary ·As a professional coder, you need the ability to properly code diagnostic tests as well as procedures and treatments for all types of neoplasms