Beth Sassano CPC, CPC-I, CPMA, CCS-P

Requirements for documenting and coding neoplasms in ICD-10-CM is similar to the current ICD-9-CM requirements. Most benign and all malignant neoplasm codes are found in chapter two of ICD-10-CM, just as in ICD-9-CM. The ICD-10-CM manual includes guidelines regarding accurate coding. Proper coding is based on detailed documentation.

 Chapter 2 in ICD-10-CM contains more than 1,540 codes found in categories C00–D49, starting with category C00, which contains codes for malignant neoplasm of the lip.  The "ICD-10-CM Official Guidelines for Coding and Reporting" includes a section on coding guidelines for neoplasms. There are some variations from ICD-9 to 10 and professionals should review the guidelines to examine the differences.  Because neoplasms can occur anywhere in the body, billing and coding staff may want to refresh anatomy and pathophysiology knowledge.

The ICD-10 guidelines provides information regarding sequencing of neoplasms. The ICD-10-CM Official Guidelines for Coding and Reporting (C.2.a) states if the treatment is directed at the malignancy, providers and coders should assign the malignancy as the principal or first- listed diagnosis. The only exception is when the patient presents solely for administration of chemotherapy, immunotherapy, or radiation therapy. Then, coders should assign the proper Z51 category code as the principal or first-listed diagnosis, with the malignancy as a secondary diagnosis while the service.

For coders to properly code a neoplasm, the medical record must include documentation as to whether the neoplasm is:  Benign  Malignant  In situ  Uncertain behavior  Where it metastasized to The Alphabetic Index contains a Neoplasm Table that corresponds to this terminology, just as it does in ICD-9-CM.

According to an article in Just Coding:  The Neoplasm Table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. Coders should then reference the Tabular List to verify that the correct code has been selected from the table and that a more specific site code does not exist.  According to the Official Guidelines for Coding and Reporting (C.2) for a primary malignant neoplasm with two or more contiguous overlapping sites, coders should classify the sites to the subcategory/code with.8 (overlapping sites), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, coders should assign codes for each site.

Correct coding and billing is dependent on why the patient is being seen, the type of malignancy, and the site. An example is carcinoma of the liver. Document:  Any alcohol abuse and dependence  Hepatitis B or C  Identify the site:  Common bile duct  Cystic duct  The “type” (examples):  Other and unspecified parts of biliary tract  Not specified as primary or secondary  Primary, unspecified as to the type

Documentation for Breast Ca should include: Estrogen receptor status  Positive or negative  Laterality (right/Left) Gender:  Male/female Site:  Which quadrant  Central  Nipple or areola  Axillary tail or  Overlapping sites of the breast

When coders or providers look up code C50.3 in the Tabular Index or the EMR, they will find that additional characters are necessary to indicate the gender of the patient and laterality.  C Malignant neoplasm of lower-inner quadrant of right female breast  C Malignant neoplasm of lower-inner quadrant of left female breast  C Malignant neoplasm of lower-inner quadrant of unspecified female breast  C Malignant neoplasm of lower-inner quadrant of right male breast  C Malignant neoplasm of lower-inner quadrant of left male breast  C Malignant neoplasm of lower-inner quadrant of unspecified male breast

The ICD-10-CM Official Guidelines for Coding and Reporting addresses sequencing of malignancies, of complications associated with the malignancies, or with the therapy. In a previous presentation we noted: If there is an encounter for management of anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the first-listed diagnosis followed by the appropriate code for the anemia. This is different than how we currently code it in ICD-9-CM.

The entries in the ICD-10-CM tabular and index for lymphoma and leukemia differ significantly from those in ICD-9-CM. Professionals should review the entries under the main terms lymphoma and leukemia in the ICD-10-CM Index.

The four common types of leukemia are:  Chronic lymphocytic leukemia  Chronic myeloid leukemia,  Acute lymphocytic (lymphoblastic) leukemia, and  Acute myeloid leukemia. 1 1 It is helpful to know the difference between lymphoid stem cells and myeloid stem cells. According to the National Cancer Institute, "A myeloid stem cell matures into a myeloid blast. The blast can form a red blood cell, platelets, or one of several types of white blood cells. A lymphoid stem cell matures into a lymphoid blast. The blast can form one of several types of white blood cells, such as B cells or T cells. Myeloid leukemia affects myeloid cells, and lymphocytic leukemia affects lymphoid cells.

Lymphoma consists of Hodgkin and non-Hodgkin lymphoma. Hodgkin lymphoma is a rare form of cancer. Non-Hodgkin lymphoma is divided into many different types;  B-cell non-Hodgkin lymphomas (such as Burkitt lymphoma)  Chronic lymphocytic leukemia/small lymphocytic lymphoma  Diffuse large B-cell lymphoma  Follicular lymphoma  Immunoblastic large cell lymphoma  Mantle cell lymphoma and  Precursor B-lymphoblastic lymphoma  Other types include T-cell non- Hodgkin lymphomas (such as anaplastic large cell lymphoma), mycosis fungoides, and precursor T- lymphoblastic lymphoma

More and more payers are denying evaluation and management (E&M) services as “incidental to another service.”  The appropriateness of a denial and appeal depends on whether the coding rules for both services were met. If the scenario is coded appropriately, your biller should definitely appeal.  If it was not reported correctly, use it as an educational opportunity, adjust the charge, and document the reason as a coding error for compliance monitoring.

An E&M service can be reported with a minor procedure if it is either a significant separate service. Ways to prove this is separate diagnoses for each service.

It is not uncommon to address more that one problem during a visit. It sometimes results in a test or a procedure. If a patient is seen for pelvic pain and the decision to perform an endometrial biopsy is performed, both can be coded and billed. However if the patient is coming in for the endometrial biopsy, they expect you to take a short history and ask how the patient is doing. That is not a separate E&M and should NOT be coded, only the biopsy should be reported.

Ensure all services are accurately reported and supported by documentation.  Append modifier 25 as appropriate, based on the payer’s definition of minor procedures.  If the claim is denied write the appeal to indicate the E&M was the significant, separate, or decision-making visit, which should not be bundled into the procedure service.  Link diagnosis(es) codes appropriately to support the medical necessity of each service.

Modifier 25 is used when a significant, separate, identifiable E&M service by the same physician is performed on the same day of the procedure or other service. It is appended to the E&M service provided on the same day as a minor surgical procedure IF the E&M service is a significant and separate service. This typically occurs when a provider sees a patient for an evaluation of a condition and decides, as a result of the E&M service, to perform a minor surgical procedure. In this case, modifier 25 can be appended to the E&M service, which can be reported in addition to the minor procedure.

Medicare will reimburse you separately for providing an E&M service on the same date as a minor procedure IF the E&M service is significantly beyond the scope of work normally associated with the procedure. This can mean that the E/M service could be unrelated to the procedure or pertain to service provided above and beyond what is typically furnished on the same date as the procedure. Again, you should bill a separate identifiable E/M service on the same date as a procedure by appending CPT modifier -25 to the E&M service.

 You should not automatically “write- off” any payer denial as “incidental or inclusive” without appealing the claim.  If the visit was accurately documented and reported, an appeal is warranted.  Management should review payer contracts for language indicating if the E&M is bundled with a minor procedure. If this language is found, reconsider modifying the contract.  Trend payer behavior. If denials consistently track to one or two payers, request a meeting with the Medical Director and outline your concerns.  The payer may need to turn off an automatic edit that is causing inappropriate denials.