ICD-10 Coding/Neoplasms
This lesson introduces ICD-10-CM Neoplasms.
Objectives and Skills
editObjectives and skills for this lesson include:
- Apply ICD-10-CM coding guidelines for accurate selection and sequencing of diagnosis codes commonly used to describe neoplasms
- Apply ICD-10-PCS coding guidelines for accurate selection of procedure codes commonly used to diagnose and treat neoplasms
Guidelines
editGuidelines Introduction Video
Chapter 2 Guidelines Powerpoint.
Start Here
editChapter 2 specific guidelines can be found on pages 29-36 of this document
Part 1: Diagnoses
editCG I.C.2. Chapter 2: Neoplasms (C00-D49) General guidelines
editCG I.C.2.a. Treatment directed at the malignancy
editCG I.C.2.b. Treatment of secondary site
editCG I.C.2.c. Coding and sequencing of complications
editCG I.C.2.c.1) Anemia associated with malignancy
editCG I.C.2.c.2) Anemia associated with chemotherapy, immunotherapy and radiation therapy
editCG I.C.2.c.3) Management of dehydration due to the malignancy
editCG I.C.2.c.4) Treatment of a complication resulting from a surgical procedure
editCG I.C.2.d. Primary malignancy previously excised
editCG I.C.2.e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy
editCG I.C.2.e.1) Episode of care involves surgical removal of neoplasm
editCG I.C.2.e.2) Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy
editCG I.C.2.e.3) Patient admitted for radiation therapy, chemotherapy or immunotherapy and develops complications
editCG I.C.2.f. Admission/encounter to determine extent of malignancy
editCG I.C.2.g. Symptoms, signs, and abnormal findings listed in Chapter 18 associated with neoplasms
editCG I.C.2.h. Admission/encounter for pain control/management
editCG I.C.2.i. Malignancy in two or more noncontiguous sites
editCG I.C.2.j. Disseminated malignant neoplasm, unspecified
editCG I.C.2.k. Malignant neoplasm without specification of site
editCG I.C.2.l. Sequencing of neoplasm codes
editCG I.C.2.l.1) Encounter for treatment of primary malignancy
editCG I.C.2.l.2) Encounter for treatment of secondary malignancy
editCG I.C.2.l.3) Malignant neoplasm in a pregnant patient
editCG I.C.2.l.4) Encounter for complication associated with a neoplasm
editCG I.C.2.l.5) Complication from surgical procedure for treatment of a neoplasm
editCG I.C.2.l.6) Pathologic fracture due to a neoplasm
editCG I.C.2.m. Current malignancy versus personal history of malignancy
editCG I.C.2.n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history
editCG I.C.2.o. Aftercare following surgery for neoplasm
editCG I.C.2.p. Follow-up care for completed treatment of a malignancy
editCG I.C.2.q. Prophylactic organ removal for prevention of malignancy
editCG I.C.2.r. Malignant neoplasm associated with transplanted organ
editPart 2 : Procedures
editExcision, Resection, or Destruction of a body part
Excision vs Resection
- Excision[1] – sentinel lymph removed
- Resection – the entire lymph node chain removed
Destruction: physical eradication of all or a portion of a body part by direct use of energy, force, or a destructive agent (Ex. Laser: Radiation Therapy)
What is the root operation for “Antineoplastic chemotherapy”? Introduction
Learning Resources
edit-
Cancer Stem Cells
Characteristics / Classifications of Neoplasms PPT [3]
How to become a Cancer Registry Professional? Website [4]
Common Surgical Procedures[5]
Activities
editCancer Pathophysiology Quiz[6]
Visit the following the National Cancer Institute website[7] and answer the following question: What is cancer?
Check your understanding:
- What is the difference between “remission” and “relapse”?[8]
- Remission
- When the disease lessens in severity
- Symptoms decrease and treatment discontinued
- Relapse
- Return of manifestations after an interval of improvement
- May be a recurrence of the leukemia
- Remission
- What is G89.3? code for neoplasm-related pain
- Where is the following guideline located ? ICD-10-CM / chapter 6 : Diseases of the Nervous System (G00 - G99)
- Coding Guideline:[9]
- Neoplasm Related Pain Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic. This code may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. The underlying neoplasm should be reported as an additional diagnosis. When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain. See Section I.C.2 for instructions on the sequencing of neoplasms for all other stated reasons for the admission/encounter (except for pain control/pain management).
-
Skin Melanoma
What does term “Malignant[10]” mean?
- Tending to become worse and cause death
- Describing a cancer
- Resistant to treatment
-
Malignant neoplasms world map 2012
Summary and Key Terms
editBAM Table:
Behavior (6 different choices) | Anatomical Site | Morphology type | |
1) Malignant Primary | site where neoplasm originated | Lung, breast, etc. | · describes the size, shape and structure of the cells; leukemia, melanoma, sarcoma, adenocarcinoma, fibroma, glioma, etc.
If morphology is stated, coder must locate the morphology of the tumor in the Index to Diseases and Injuries · For example, lipoma, melanoma, sarcoma have specific codes included in the Index · However, not every entry in Index will include codes · For example, glioma, subependymal, brain has a cross reference to – see Neoplasm, uncertain behavior, by site (brain) |
Malignant Primary with Contiguous Sites | Overlaps 2 or more contiguous sites should be classified to the subcategory/code “.8” (unless the combination is specifically indexed elsewhere | Ex: Lesion of the jejunum and ileum | |
2) Malignant Secondary | · site to which neoplasm has spread (also known as the metastatic site)
· patient may have a metastatic tumor, but the site of the primary tumor cannot be found · “new primary” occurs when patient develops cancer a second time and is unrelated to the first cancer site · “recurrence” is when the original cancer recurs in the same organ · Cells of the secondary site do not resemble the cells of the organ where it was found - Patient stated as having an unknown primary origin - Code for secondary site where found - Code for primary malignant of unknown site |
||
3) In situ (in place) | malignant changes in cells but surrounding tissue has not been invaded | ||
4) Benign | tumor growth does not invade adjacent structures or spread to distant sites | ||
5) Uncertain | pathologist cannot determine whether benign or malignant | ||
6) Unspecified Behavior | neither the behavior nor the histology is specified in the diagnosis Ex: “Growth,” “Neoplasm,” “Tumor” |
See Also
edithttps://en.wikipedia.org/wiki/ICD-10_Chapter_II:_Neoplasms[11]
Reporting Pain in ICD-10-CM[12]
References
edit- ↑ Jennifer Whitlock RN MSN (May 29, 2018). "How and Why Excisions Are Performed During a Surgery". Verywell Health. Retrieved 2019-05-10.
- ↑ Cancer, retrieved 2019-05-10
- ↑ Subramani Parasuraman (2013-10-20). Neoplasia Characteristics and classification of cancer. https://www.slideshare.net/ParasuramanParasuraman/neoplasia-1-27391892.
- ↑ BECOMING A CANCER REGISTRY PROFESSIONAL - SEER REGISTRARS In-text: (SEER, 2019) Your Bibliography: SEER. (2019). Becoming a Cancer Registry Professional - SEER Registrars. [online] Available at: https://seer.cancer.gov/registrars/howto.html [Accessed 10 May 2019].
- ↑ "Surgical Procedures". Verywell Health. Retrieved 2019-05-10.
- ↑ "Cancer Pathophysiology Quiz". Health Information Technology Notifications | HITNOTS. 2015-07-14. Retrieved 2019-05-10.
- ↑ "What Is Cancer?". National Cancer Institute. 2007-09-17. Retrieved 2019-05-10.
- ↑ "Remission vs. Relapse". Sarah Cannon. Retrieved 2019-05-10.
- ↑ "Acrobat Accessibility Report" (PDF). www.cms.gov. Retrieved 2019-05-10.
- ↑ "NCI Dictionary of Cancer Terms". National Cancer Institute. 2011-02-02. Retrieved 2019-05-10.
- ↑ "ICD-10 Chapter II: Neoplasms". Wikipedia. 2018-05-10. https://en.wikipedia.org/w/index.php?title=ICD-10_Chapter_II:_Neoplasms&oldid=840572757.
- ↑ "Reporting Pain in ICD-10-CM". Coding Strategies. Retrieved 2019-05-10.