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Part 1
Neoplasms
Neoplasm
Behaviors - Coding
Neoplasms - Sequencing
Neoplasms
A neoplasm is abnormal tissue that grows
by cellular proliferation more rapidly than normal tissue.
Its growth continues even after the stimuli that started the
growth have ended. Neoplasms lack structural organization
and functional coordination with normal tissue, usually forming
a distinct mass. The coding of neoplasms requires a good understanding
of anatomy and medical terminology as this article will show.
In ICD-9-CM, all neoplasms are classified to Chapter 2 in
the Tabular List. The Table of Neoplasms in the Alphabetic
Index lists code numbers for neoplasms by anatomical site.
Code numbers representing six types of neoplasm behavior are
listed for each site.
Malignant neoplasms are composed of
tumor cells that can invade surrounding structures or distant
organs. Their growth is more rapid than that of benign neoplasms.
ICD-9-CM classifies malignant neoplasms as primary, secondary,
and carcinoma in situ. Primary identifies the site
of origin of the neoplasm. The point of origin is determined
through study of the morphology (form and structure) of the
tumor cells. Determination of the point of origin and type
of cells is important in establishing the severity of illness
and planning treatment. Secondary identifies the site(s)
to which the primary site has spread by direct extension to
surrounding tissues or metastasized by lymphatic spread, invasion
of blood vessels, or implantation as tumor cells are shed
into body cavities. The morphology of a metastatic neoplasm
is the same as that of the primary neoplasm. Carcinoma in
situ is composed of tumor cells which are undergoing malignant
changes; however, these changes do not extend beyond the point
of origin or invade surrounding normal tissue. Carcinoma in-situ
is also described as non-infiltrating, non-invasive, or pre-invasive
carcinoma.
Benign neoplasms are tumors which
do not invade adjacent structures or spread to distant sites.
Their growth may displace or exert pressure on adjacent structures.
The impingement on surrounding organs can result in local
symptoms. Some benign neoplasms have no potential for malignancy.
However, others, such as adenomatous gastric polyps, have
a pre-malignant potential, and removal is indicated. Fortunately,
most benign tumors can be completely excised.
The classification Of Uncertain Behavior
includes tumors which show features of both benign and malignant
behavior. These tumors may require further study before a
definitive diagnosis can be established. The codes in this
category should only be assigned when documentation by the
pathologist clearly indicates that the behavior of the neoplasm
cannot be identified.
If neither the behavior nor histological
type of tumor are specified in the diagnostic statement, a
neoplasm is classified to be of Unspecified Nature.
This type of diagnosis may be encountered when the patient
has been treated elsewhere and now presents to a different
facility without accompanying information, is referred elsewhere
for definitive work-up, or work-up is not performed due to
the patient’s advanced age or poor condition.
ICD-9-CM classifies neoplasms by system,
organ, or site. Exceptions to this are lymphatic and hematopoietic
neoplasms, malignant melanoma of the skin, and some common
tumors of bone, uterus, and ovary. Because of these exceptions,
the alphabetic index should be checked first to see if there
is a specific code assigned to a listed morphological type,
such as sarcoma, adenoma, and melanoma. The alphabetic listing
also directs coders to the appropriate classification of neoplasms
which do not have a code for a specific morphological type.
For example, Osteoma directs coders to "see
Neoplasm, bone, benign." A note at the beginning
of the Neoplasm Table instructs coders that guidance in the
alphabetic index may be overridden if a descriptor is present.
For example, malignant adenoma of the colon is coded to 153.9
rather than 211.3 because the adjective "malignant"
overrides the index entry "Adenoma--see also Neoplasm,
benign."
If a specific neoplasm diagnosis indicates
which column of the Neoplasm Table is appropriate and does
not delineate a specific type of tumor, the table may be consulted
directly. Some sites on the table are marked with an asterisk
(*), such as "extremity*" or "knee,
NEC*." These should be classified to malignant neoplasm
of the skin of these sites if the type of neoplasm is a squamous
cell carcinoma or epidermoid carcinoma and to benign neoplasm
of the skin of these sites if the neoplasm is any type of
a papilloma.
Primary neoplasms are classified to the site
of origin. In the case of malignant neoplasms originating
from contiguous sites, it may not be possible to delineate
the point of origin. These neoplasms are given the fourth
digit assignment of 8. For example, a malignant neoplasm
of overlapping sites of the pancreas is coded to 157.8,
Malignant neoplasm of contiguous or overlapping sites of pancreas
whose point of origin cannot be determined.
ICD-9-CM includes two categories that depart
from the usual principles of classification. These codes are
150, Malignant neoplasm of the esophagus, and 201,
Hodgkin’s disease. In these codes the fourth digit
subdivisions are not mutually exclusive. This dual-axis classification
allows for variation in terminology used by physicians. For
example, different physicians may describe the same neoplasm
as being located in the thoracic esophagus (150.1) or the
middle third of the esophagus (150.4).
When treatment is directed at the primary
site of the malignancy, the primary site is designated as
the principal diagnosis. An exception to this is if the hospital
admission or encounter is solely for the administration of
radiotherapy (V58.0) or chemotherapy (V58.1). In these instances,
the V-code is sequenced as the principal diagnosis and the
malignancy, either primary or secondary, as a secondary diagnosis.
The malignancy should be coded using codes in the 140-198
or 200-203 series for as long as adjunct chemotherapy or radiotherapy
is being administered.
If the primary malignancy has been excised
or eradicated and the patient is not receiving adjunct treatment
to the site and shows no evidence of remaining malignancy,
a code from the V10 series, Personal history of malignant
neoplasm, is assigned. The fourth and fifth digits specify
the site of the primary malignancy. Any extension, invasion,
or metastasis to another site is coded as a secondary malignant
neoplasm. If treatment of the secondary neoplasm is the reason
for admission, it is sequenced as the principal diagnosis.
If a secondary malignancy is not present
and the patient is admitted for follow-up, two codes are required.
For example, if a patient is admitted for follow-up of carcinoma
of the colon following radiotherapy and recurrence is not
found, V67.1, Follow-up examination following radiotherapy,
is sequenced as the principal diagnosis. V10.05, Personal
history of malignant neoplasm of the large intestine,
is a secondary diagnosis. Malignancies of the hematopoietic
and lymphatic tissue specified as "in remission"
are assigned codes from the V10.60-V10.79 series. If the primary
malignancy has recurred, it is coded as a primary malignancy
of the designated site and sequenced as dictated by the circumstances
of admission. V-codes would not be used in this situation.
Because of the ambiguity sometimes seen when
a diagnosis of metastatic carcinoma is given, rules have been
implemented for clarification. Cancer "metastatic to"
a site is interpreted as a secondary neoplasm of that site.
For example, metastatic carcinoma to the liver is coded as
197.7, Neoplasm of the liver, specified as secondary.
Cancer described as "metastatic from" a site
is interpreted as a primary malignancy of that site. A diagnosis
of metastasis from the thyroid is coded to 193, Malignant
neoplasm of the thyroid gland. Secondary codes are assigned
for the metastatic sites.
If the diagnostic statement lists only one
site and it is identified as metastatic, it should be coded
as a primary neoplasm of unspecified site for the morphological
type. If the morphological type is not identified in the medical
record, the site qualified as metastatic is coded as a primary
malignant neoplasm of the given site unless it is one of the
following sites:
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- Sites classifiable to 195
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These sites are coded as secondary neoplasms
unless they are otherwise designated. Appropriate codes should
also be assigned for the primary or secondary malignant neoplasms
of the specified or unspecified sites included in the diagnostic
statement. For example, a diagnosis of metastatic carcinoma
of the peritoneum is coded to 197.6, Secondary malignant
neoplasm of retroperitoneum and peritoneum, and 199.1,
Malignant neoplasm without specification of site, other.
In this case, the peritoneum is one of the sites listed as
an exception, resulting in a code assignment of secondary
neoplasm of the peritoneum and primary malignant neoplasm
of an unspecified site.
A diagnosis of metastatic carcinoma of the
ovary would be coded to 183.0, Malignant neoplasm of ovary,
and 199.1, Malignant neoplasm without specification of
site, other. Since the site mentioned is not one of the
exceptions, it is coded as a primary neoplasm of the stated
site, and the secondary neoplasm is coded as an unspecified
site.
If two or more sites are documented as metastatic
in the diagnostic statement, the stated sites should be coded
as secondary neoplasms and the primary site as unknown. In
the event the diagnosis does not specify a site, but the morphological
type is documented as metastatic, codes should be assigned
for a primary neoplasm of unknown site and secondary neoplasm
of unspecified site.
If a neoplasm is determined to be the reason
for admission, the focus of treatment can be used to select
the correct code for the principal diagnosis. If treatment
is directed toward the primary neoplasm, it is sequenced as
the principal diagnosis. If admission is for treatment directed
only at a secondary site, the metastatic site is sequenced
as the principal diagnosis and the primary site as a secondary
diagnosis.
An exception is the admission for the administration
of radiotherapy or chemotherapy. In this event, the principal
diagnosis is V58.0 or V58.1 followed by the secondary code(s)
for the site(s) of the malignancy. If the patient is admitted
for definitive therapy such as surgery, diagnostic procedures,
staging, or palliative procedures and receives radiotherapy
or chemotherapy during the admission, the malignancy is sequenced
as the principal diagnosis, and V-codes are not assigned.
If a patient is admitted with a symptom,
sign, or ill-defined condition associated with a malignancy,
the malignancy is sequenced as the principal diagnosis. Basic
coding guidelines dictate that if a related definitive diagnosis
has been established as the cause of the symptom(s), it should
be sequenced first.
Frequently, a patient with a malignancy will
be admitted with an acute condition such as anemia or dehydration.
This may be due to the malignancy itself or the therapy received.
If treatment is directed toward the acute condition, it is
sequenced as the principal diagnosis and the malignancy as
a secondary diagnosis.
In coding neoplasms, three factors must be
taken into consideration:
Understanding and following the guidelines
outlined in this article then ensures the selection of accurate
codes and correct identification and sequencing of principal
and secondary diagnoses.
Back to:
Top - Neoplasm
Behaviors - Coding
Neoplasms - Sequencing
Neoplasms
Part
2: Grading and Staging of Cancer
If you have comments or suggestions about our code selections
or about any topic on our Coding Edge® pages, please e-mail
us at codingedge@lagunamedsys.com.
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