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Chapter - 2

Chapter 2 of the ICD-10-CM outlines the coding for benign and malignant neoplasms, emphasizing the need to determine the nature of the neoplasm and the appropriate principal diagnosis based on treatment focus. It details coding guidelines for various scenarios, including treatment of complications, management of anemia, and admissions for chemotherapy or radiation therapy. Additionally, it addresses the coding for multiple malignancies and the use of specific codes for complications arising from treatment or surgical procedures.

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15 views19 pages

Chapter - 2

Chapter 2 of the ICD-10-CM outlines the coding for benign and malignant neoplasms, emphasizing the need to determine the nature of the neoplasm and the appropriate principal diagnosis based on treatment focus. It details coding guidelines for various scenarios, including treatment of complications, management of anemia, and admissions for chemotherapy or radiation therapy. Additionally, it addresses the coding for multiple malignancies and the use of specific codes for complications arising from treatment or surgical procedures.

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Joanna
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© © All Rights Reserved
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Chapter 2

Neoplasms

(C00-D49)
 Chapter 2 of the ICD-10-CM contains the codes for most benign and all
malignant neoplasms. Certain benign neoplasms, such as prostatic
adenomas, may be found in the specific body system chapters.
 To properly code a neoplasm, it is necessary to determine from the
record if the neoplasm is benign, in-situ, malignant, or of uncertain
histologic behavior. If malignant, any secondary (metastatic) sites should
also be determined.
Treatment directed at the malignancy
 If the treatment is directed at the malignancy, designate the malignancy
as the principal diagnosis.
 The only exception to this guideline is if a patient admission/encounter is
solely for the administration of chemotherapy, immunotherapy or
external beam radiation therapy, assign the appropriate Z51.-- code as
the first-listed or principal diagnosis, and the diagnosis or problem for
which the service is being performed as a secondary diagnosis.
Treatment of secondary site
 When a patient is admitted because of a primary neoplasm with
metastasis and treatment is directed toward the secondary site only, the
secondary neoplasm is designated as the principal diagnosis even though
the primary malignancy is still present.
Coding and sequencing of complications
Anemia associated with malignancy
 When admission/encounter is for management of an anemia associated
with the malignancy, and the treatment is only for anemia, the
appropriate code for the malignancy is sequenced as the principal or first-
listed diagnosis followed by the appropriate code for the anemia (such as
code D63.0, Anemia in neoplastic disease).
Anemia associated with chemotherapy, immunotherapy and
radiation therapy
 When the admission/encounter is for management of an anemia
associated with an adverse effect of the administration of
chemotherapy or immunotherapy and the only treatment is for
the anemia, the anemia code is sequenced first followed by the
appropriate codes for the neoplasm and the adverse effect
(T45.1X5-, Adverse effect of antineoplastic and
immunosuppressive drugs).
 When the admission/encounter is for management of an anemia
associated with an adverse effect of radiotherapy, the anemia code
should be sequenced first, followed by the appropriate neoplasm code
and code Y84.2, Radiological procedure and radiotherapy as the cause of
abnormal reaction of the patient, or of later complication, without
mention of misadventure at the time of the procedure.
Management of dehydration due to the malignancy
 When the admission/encounter is for management of dehydration due to
the malignancy and only the dehydration is being treated (intravenous
rehydration), the dehydration is sequenced first, followed by the code(s)
for the malignancy.
Treatment of a complication resulting from a surgical procedure
 When the admission/encounter is for treatment of a complication
resulting from a surgical procedure, designate the complication as the
principal or first-listed diagnosis if treatment is directed at resolving the
complication.
Primary malignancy previously excised
 When a primary malignancy has been previously excised or eradicated
from its site and there is no further treatment directed to that site and
there is no evidence of any existing primary malignancy at that site, a
code from category Z85, Personal history of malignant neoplasm, should
be used to indicate the former site of the malignancy.
 Any mention of extension, invasion, or metastasis to another site
is coded as a secondary malignant neoplasm to that site. The
secondary site may be the principal or first-listed diagnosis with
the Z85 code used as a secondary code.

Admissions/Encounters involving chemotherapy,


immunotherapy and radiation therapy
Episode of care involves surgical removal of neoplasm
 When an episode of care involves the surgical removal of a
neoplasm, primary or secondary site, followed by adjunct
chemotherapy or radiation treatment during the same episode of
care, the code for the neoplasm should be assigned as principal
or first-listed diagnosis.
Patient admission/encounter solely for administration of
chemotherapy, immunotherapy and radiation therapy
 If a patient admission/encounter is solely for the administration of
chemotherapy, immunotherapy or external beam radiation therapy
assign code Z51.0, Encounter for antineoplastic radiation therapy, or
Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12,
Encounter for antineoplastic immunotherapy as the first-listed or
principal diagnosis. If a patient receives more than one of these therapies
during the same admission more than one of these codes may be
assigned, in any sequence.
 The malignancy for which the therapy is being administered should be
assigned as a secondary diagnosis.
 If a patient admission/encounter is for the insertion or implantation of
radioactive elements (e.g., brachytherapy) the appropriate code for the
malignancy is sequenced as the principal or first-listed diagnosis. Code
Z51.0 should not be assigned.
Patient admitted for radiation therapy, chemotherapy or
immunotherapy and develops complications
 When a patient is admitted for the purpose of external beam
radiotherapy, immunotherapy or chemotherapy and develops
complications such as uncontrolled nausea and vomiting or
dehydration, the principal or first-listed diagnosis is Z51.0,
Encounter for antineoplastic radiation therapy, or Z51.11,
Encounter for antineoplastic chemotherapy, or Z51.12, Encounter
for antineoplastic immunotherapy followed by any codes for the
complications.
 When a patient is admitted for the purpose of insertion or
implantation of radioactive elements (e.g., brachytherapy) and
develops complications such as uncontrolled nausea and vomiting
or dehydration, the principal or first-listed diagnosis is the
appropriate code for the malignancy followed by any codes for the
complications.
Admission/encounter to determine extent of malignancy
 When the reason for admission/encounter is to determine the extent of
the malignancy, or for a procedure such as paracentesis or
thoracentesis, the primary malignancy or appropriate metastatic site is
designated as the principal or first-listed diagnosis, even though
chemotherapy or radiotherapy is administered.

Malignancy in two or more noncontiguous sites


 A patient may have more than one malignant tumor in the same organ.
These tumors may represent different primaries or metastatic disease,
depending on the site.
 Should the documentation be unclear, the provider should be queried
as to the status of each tumor so that the correct codes can be
assigned.
Disseminated malignant neoplasm, unspecified
 Code C80.0, Disseminated malignant neoplasm, unspecified, is
for use only in those cases where the patient has advanced
metastatic disease and no known primary or secondary sites
are specified.
 It should not be used in place of assigning codes for the
primary site and all known secondary sites.

Malignant neoplasm without specification of site


 Code C80.1, Malignant (primary) neoplasm, unspecified,
equates to Cancer, unspecified. This code should only be used
when no determination can be made as to the primary site of a
malignancy. This code should rarely be used in the inpatient
setting.
Sequencing of neoplasm codes
Encounter for treatment of primary malignancy
 If the reason for the encounter is for treatment of a primary
malignancy, assign the malignancy as the principal/first-listed
diagnosis. The primary site is to be sequenced first, followed by
any metastatic sites.

Encounter for treatment of secondary malignancy


 When an encounter is for a primary malignancy with metastasis
and treatment is directed toward the metastatic (secondary)
site(s) only, the metastatic site(s) is designated as the
principal/first-listed diagnosis. The primary malignancy is coded as
an additional code.

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