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

2. 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

3. 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

4. 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

5. 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)

6. 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)

7. “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.-)

8. 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

9. 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.

10. 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.

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

12. NEOPLASM TABLE

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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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:
C E Hyperestrogenism due to carcinoma of right ovary.

19. 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-)

20. 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.

21. 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.

22. 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
E C25.9

23. 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

24. 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-

25. 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

26. 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.

27. QUESTIONS