Download Primary neoplasm

Chapter 6B
ICD-10-CM Coding
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ICD-10-CM
• International Classification of Diseases,
10th Revision, Clinical Modification
– Developed in the United States
– Used to classify morbidity data from inpatient and
outpatient records
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ICD-10-PCS
• International Classification of Diseases, 10th
Revision, Procedure Classification System
– Developed in the United States
– Used to classify procedures from inpatient records only
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ICD-9-CM Legacy Coding System
• Effective October 1, 2013, when ICD-10-CM
and ICD-10-PCS are implemented, the
ICD-9-CM will become a legacy coding system.
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© Cengage Learning 2013
Transition to ICD-10-CM/PCS
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© Cengage Learning 2013
Transition to ICD-10-CM/PCS
(cont.)
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© Cengage Learning 2013
Transition to ICD-10-CM/PCS
(cont.)
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Mandatory
Reporting of ICD-10-CM/PCS
Codes
• Effective October 1, 2013, ICD-10-CM will
be used for all diagnosis coding and
ICD-10-PCS will be used for inpatient
hospital procedure coding.
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General Equivalency Mappings
• These are translation crosswalks used to
roughly identify ICD-10-CM codes and their
ICD-9-CM equivalent codes.
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Purpose of Reporting ICD-10-CM
Codes
• Medical necessity
– Determination that a service or procedure rendered is
reasonable and necessary for the diagnosis or treatment
of an illness or injury
• Reporting a ICD-10-CM justifies the
procedure codes reported.
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ICD-10-CM Index to Diseases and
Injuries
• Alphabetic listing of terms that include
–
–
–
–
–
Specific illnesses
Injuries
Eponyms
Abbreviations
Other descriptive diagnostic terms
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ICD-10-CM Index
• The index of ICD-10-CM contains
– Index to Diseases and Injuries
• Table of Neoplasms
• Table of Drugs and Chemicals
– Index to External Causes
• Main terms, subterms, and qualifiers are
used to locate codes in the index.
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Index to Diseases
• Main terms
– Printed in boldface type and are followed by the code
number
• Subterms (essential modifiers)
– Qualify the main term by listing alternate sites,
etiology, or clinical status
• Qualifiers
– Supplementary terms that modify subterms
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ICD-10-CM Coding Conventions
•
•
•
•
•
•
•
•
Format and typeface
Eponyms and abbreviations
Punctuation
Tables
Notes, excludes, and inclusion
Etiology and manifestation rules
“And”, “Due to”, “With”
Cross references
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Neoplasm Table
• Neoplasms
– New growths or tumors, where cell reproduction is out
of control.
– Provider should specify whether the tumor is benign or
malignant.
– Neoplasms should be coded from the pathology report.
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Neoplasm Table
• Indexed by anatomic site and contains four
cellular classifications
– Malignant
• Primary
• Secondary
• Carcinoma in situ
– Benign
– Uncertain behavior
– Unspecified
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Neoplasm Table
• Primary malignancy
– Original tumor site
– All malignant tumors are considered primary
• Unless otherwise documented as metastatic or secondary
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Neoplasm Table (cont.)
• Primary malignancy
– Malignancy is coded as the primary site if the
diagnostic statement documents
•
•
•
•
•
Metastatic from a site
Spread from a site
Primary neoplasm of a site
Malignancy for which no specific classification is documented
Recurrent (repeating) tumor
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Neoplasm Table (cont.)
• Secondary malignancy
– Tumor has spread to a secondary site.
• Either adjacent to the primary site or to a distant area of the
body
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Secondary Malignancies
• Metastatic and show that a primary cancer
has spread to another area.
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Secondary Malignancies (cont.)
• Cancer described as metastatic from a site is
primary of that site.
– Assign code to the primary neoplasm.
– Assign second code to the secondary neoplasm of the
specified site or unspecified site.
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Secondary Malignancies (cont.)
• Cancer described as metastatic to a site is
considered secondary of that site.
– Assign one code to the secondary site and a second
code to the specified primary site or unspecified site.
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Secondary Malignancies (cont.)
• When anatomic sites are recognized as
metastatic
– Assign secondary neoplasm code(s) to those sites.
– Assign unspecified site code to the main malignant
neoplasm.
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Secondary Malignancies (cont.)
• If the diagnostic statement does not specify
whether the neoplasm site is primary or
secondary
– Code the site as primary unless the documented site is
one of the following: bone, brain, diaphragm, heart,
liver, lymph nodes, mediastinum, meninges,
peritoneum, pleura, retroperitoneum, or spinal cord.
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Anatomic Site Not Documented
• If the cancer diagnosis does not contain
documentation of the anatomic site but the
term metastatic is documented, then assign
codes for “unspecified site” for both the
primary and secondary sites.
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Primary Malignancy Site No
Longer Present
• Do not assign the code for primary
unspecified site. Instead, classify the
previous primary site by assigning the
appropriate code from category Z85,
“Personal history of malignant neoplasm.”
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Contiguous or Overlapping Sites
• Contiguous sites (or overlapping sites)
occur when the origin of the tumor (primary
site) involves two adjacent sites.
• Neoplasms with overlapping site boundaries
are classified to the fourth-digit subcategory
.8, “Other.”
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Re-excision of Tumor
• A surgeon, when performing a second
excision to widen the margins of the
original tumor site
– Ensures that all tumor cells have been removed.
– Uses the diagnostic statement found in the report of the
original excision to code the reason for the re-excision.
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Coding Tip
• Read notes that apply to the condition you
are coding.
• Never assign a code directly from the table
or Index to Diseases.
• Be certain codes represent the current status
of the neoplasm.
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Coding Tip
• Assign a neoplasm code
– If a tumor has been excised and the patient is still
undergoing radiation or chemotherapy
• Assign a Z code
– If a tumor is not present
– If a patient is not receiving treatment but is returning
for follow-ups
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Coding Tip
• In a pathology report
– Classification stated on a pathology report overrides
morphology classification in the Index to Diseases.
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Table of Drugs and Chemicals
• Alphabetic index of medicinal, chemical,
and biological substances that result in
poisonings, adverse effects, and
underdosing.
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Table of Drugs and Chemicals
• Six columns in the table
–
–
–
–
–
–
Poisoning: Accidental
Poisoning: Intentional Self-harm
Poisoning: Assault
Poisoning: Undetermined
Adverse effects
Underdosing
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Table of Drugs and Chemicals
Codes in categories T36 to T65 are
combination codes that include the
substance related to the adverse effect,
poisoning, toxic effects, and underdosing,
as well as the external cause.
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Official Guidelines for Coding
The occurrence of drug toxicity is classified as
• Adverse effects
• Poisoning
• Underdosing
• Toxic effects
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Index to External Causes
• These are arranged in alphabetical order,
indicating the main event that caused
the injury.
• These codes are secondary codes.
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ICD-10-CM Tabular List
• Chronological list of codes contained in the
21 chapters
• Based on body system or condition
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Tabular List
• Major topic headings, also called code
block
– Printed in bold uppercase letters and followed by codes
in parentheses
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Tabular List
• Categories
– Major topics are divided into three-character categories.
• Subcategories
– These contain either four or five characters.
• Codes may contain three, four, five, six, or
seven characters.
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Placeholder character
• ICD-10-CM uses the character “x” as a
placeholder.
• When a placeholder exists, the x must be
entered in order for the code to be considered
valid.
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ICD-10-CM External Cause Codes
• Injury, poisoning, and certain other
consequences of external causes of
morbidity are incorporated in
ICD-10-CM in
– Chapter 19 – S and T codes
– Chapter 20 – V-Y codes
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ICD-10-CM Health Status and
Contact with Health Services Codes
• Factors influencing health status and contact
with health services are found in Chapter 21
of the ICD-10-CM (Z codes).
• These codes are always reported as diagnosis
codes.
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Morphology of Neoplasm Codes
• Effective October 1, 2013, provider offices
will report morphology codes.
• Morphology indicates the tissue type of a
neoplasm.
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Official Guidelines for Coding and
Reporting
• CMS and NCHS prepare the
ICD-10-CM Official Guidelines for Coding
and Reporting.
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ICD-10-CM Guidelines Sections
• Section I: Conventions, general coding
guidelines, and chapter-specific guidelines
• Section II: Selection of principal diagnosis
• Section III: Reporting additional diagnosis
• Section IV: Diagnostic coding and reporting
guidelines for outpatient services
• Appendix I: Present on admission reporting
guidelines
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Guidelines for Outpatient Services
• Selection of first-listed diagnosis
• ICD-10-CM Tabular List of Diseases
• Accurate reporting of ICD-10-CM diagnosis
codes
• Codes that describe signs and symptoms
• Encounters for circumstances other than a
disease or injury (Z codes)
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Guidelines for Outpatient Services
(cont.)
• Level of detail in coding
• ICD-10-CM code for the diagnosis, condition,
problem, or other reason for encounter/visit
• Uncertain diagnosis
• Chronic diseases
• Code all documented conditions that coexist
• Patients receiving diagnostic services only
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Guidelines for Outpatient Services
(cont.)
• Patients receiving therapeutic services only
• Patients receiving preoperative evaluations
only
• Ambulatory surgery or outpatient surgery
• Routine outpatient prenatal visits
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Guidelines for Outpatient Services
(cont.)
• Encounters for general medical examinations
with abnormal findings
• Encounters for routine health screenings
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