1. 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

2. Learning Outcomes ·Explain the difference between benign and malignant. ·Identify the various types of neoplasms. ·Determine the proper sequence of coding multiple neoplasms. 5 - 2

3. Learning Outcomes ·Distinguish between primary and secondary malignancies. ·Use morphology codes correctly. ·Apply the guidelines for coding admissions for the treatment of complications. 5 - 3

4. Introduction ·A neoplasm is abnormal tissue growth or a tumor. ·Not all neoplasms are malignant. ·Cancer is the common term for carcinoma or malignancy. 5 - 4

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

6. 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

7. Neoplasm Table ·Ca in situ [Malignant]: Tumor has undergone malignant changes but has not spread. ·Benign: Not cancerous ·Uncertain behavior: Pathologist cannot determine. 5 - 7

8. 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. 5 - 8

9. 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. 5 - 9

10. Overlapping Boundaries ·A malignancy without clear or identifiable borders affecting multiple anatomical sites ·Use an “other specified sites” descriptor or “multiple sites.” 5 - 10

11. 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 5 - 11

12. 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. 5 - 12

13. Excised Malignancies ·Report an excised malignancy with a Personal History of... V code. ·List the V code after any current neoplastic conditions. 5 - 13

14. 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. 5 - 14

15. 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. 5 - 15

16. Complications Treatment of complications: ·Code the complication first, followed by the code for the neoplasm(s). 5 - 16

17. 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. 5 - 17