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HS317b - Advanced Health Informatics
Neoplasms Chapter II
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Cancer - see also Neoplasm, malignant(8000/3)
Malignant
Carcinoma In Situ
 Refers to neoplastic cells in a preinvasive stage of cancer
 Other terms: intraepithelial, noninfiltrating, non-invasive, preinvasive
Morphology Classification
 Describes the cell of origin (histological type)
 Describes the behaviour of neoplasm
 Optional to use
 Consists of five digits:
o First four identify histological type of neoplasm
o /Fifth indicates behaviour
 /0 Benign
 /1 Uncertain whether benign or malignant
 /2 Carcinoma in situ
 /3 Malignant, primary site
 /6 Malignant, metastatic site
 /9 Malignant, uncertain whether primary or metastatic
The ICD-O behaviour digit /9 is not applicable in the ICD context, since all malignant neoplasms
are presumed to be primary (/3) or secondary (/6), according to other information in the medical
record.
A coding difficulty sometimes arises where a morphological diagnosis contains two qualifying
adjectives that have different code numbers. An example is "transitional cell epidermoid
carcinoma". "Transitional cell carcinoma NOS" is 8120/3 and "epidermoid carcinoma NOS" is
8070/3. In such circumstances, the higher number (8120/3 in this example) should be used, as it
is usually more specific
Neoplasm
 Note MRDx definition – code based on what they are treating. A secondary site can be
MRDx if it is accountable for the patient’s LOS
 Specificity Standard
 Assign a separate code for each primary and secondary
o Includes Lymphatic & haematopoietic tissues if documented in more than one site
 C80 Malignant neoplasm without specification if documentation vague in identifying a
primary but a secondary was clearly diagnosed.
 Morphology optional
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HS317b - Advanced Health Informatics
Neoplasms Chapter II
Primary Neoplasm:
 Invasion extending into adjacent tissue, still connected to original site
o Code to point of origin
 Overlapping Boundaries (Contiguous Sites)
o Within a 3-digit category, point of origin undetermined
 Classify to subcategory .8
o Separate 3-digit category, point of origin undetermined
 Code Ca of overlapping site
o See notes at the beginning of Chapter II for overlapping code

If documentation not clear whether malignancy is primary or secondary Q 4024
o Always presume to be primary
o Exceptions: bone, brain, diaphragm, heart, lymph nodes, mediastinum, meninges,
peritoneum, pleura, retroperitoneum and spinal cord
 These are presumed to be secondaries
Follow up admissions
 Recurrent Malignancies
o Previously eradicated but recurred in same organ or tissue
o Code as primary + personal history of malignancy
 Admission for definitive intervention after diagnosis of cancer made
o MRDx: primary neoplasm
o Also when pathology is negative for malignancy and the intent is to remove
cancer
 Observation for suspected malignant neoplasm
o Z03.1 Observation for suspected malignant neoplasm
o Malignancy ruled out
o No further treatment is necessary
History of Malignant Neoplasms
 Personal history of malignant neoplasm Z85.~
o Never to be used as MRDx
o Assign diagnosis type 3
o Not assigned for secondary malignancy
o Assign only for primary neoplasm when:
 The malignancy has been completely eradicated or excised
 No further treatment is being directed to primary site
 There is no evidence of any remaining malignancy at primary site
 There is a recurrence at the same site that was previously excised
 Follow up examination after treatment for malignant neoplasm Z08.~ when no disease is
found
 Family History of Malignancy Neoplasm
o Never used as MRDx
o Denotes reason for prophylactic organ removal
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HS317b - Advanced Health Informatics
Neoplasms Chapter II
Prophylactic Organ Removal Z40.~ ~
 No disease is present
 Family history of malignancy
 Tests PSA (Prostate Specific Antigen) or CA 125 (Cancer Antigen) positive
Complications of Malignant Disease
If complications are the cause for admission
 Code as most responsible diagnosis
 Code malignancy as diagnosis type 3
o Common complications:
 Bacterial sepsis A40.~ or A41.~
 Chemotherapy induced neutropenia D70.0 with Y43.~
 Febrile neutropenia D70.0 (Q 7676) + Fever, unspecified R50.9
 Dehydration
 Hypercalcemia
Neutropenia: an abnormally low level of neutrophils in the blood. Neutrophils are white blood
cells produced in the bone marrow that ingest bacteria. It is sometimes called agranulocytosis or
granulocytopenia. It is a serious disorder because it makes the body vulnerable to bacterial &
fungal infections.
Dagger/Asterisk
 Anaemia
o in neoplastic disease NEC (see also Neoplasm) (8000/1) D48.9 D63.0
 Pathological fracture
o Bone - – – in (due to) neoplastic disease NEC (see also Neoplasm) D48.9 M90.7
Summary:
 Has the malignancy been either excised or eradicated (surgically or non-surgically)?
 Is no further treatment being directed to the primary site?
 Is there no further evidence of remaining malignancy at the primary site
Interventions
o MRDx is Z51.1 Chemotherapy session for neoplasm
o Neoplasm (active & historical malignancies) may be coded as diagnosis type 3
o Intervention: 1.ZZ.35.~ ~ (identify specific drug) for systemic or total
chemotherapy
o Radiation therapy Z51.0
o Neoplasm (active & historical malignancies) may be coded as diagnosis type 3
o Intervention 1.~~.27.~~~~ Radiation therapy includes anatomical site + type of
radiation
o Brachytherapy 1.QT.26.~~.~~ (implant of radioactive material)
o MRDx is Malignancy
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HS317b - Advanced Health Informatics
Neoplasms Chapter II
Interventions
o Therapeutic – destruction, excision partial, excision total, excision radical, Excision with
reconstruction
o Diagnostic – inspection, biopsy
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