Neoplasms
(ICD-10-CM Chapter 2, Codes C00-D49)
Learning Objectives
2. Identify pertinent anatomy and physiology of neoplasms
3. Identify neoplastic diseases
4. Assign the correct Z codes and procedure codes related to neoplasms
5. Identify common treatments, medications, laboratory values, and diagnostic tests
6. Explain the importance of documentation in relation to MS-DRGs for reimbursement
Abbreviations/Acronyms
AIDS acquired immunodeficiency syndrome
ALL acute lymphocytic leukemia
BMR biological response modifier
CDC Centers for Disease Control and Prevention
CLL chronic lymphocytic leukemia
CML chronic myelogenous leukemia
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
MS-DRG Medicare severity diagnosis-related group
NSCLC non–small cell lung cancer
UHDDS Uniform Hospital Discharge Data Set
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
2. Chapter 2: Neoplasms (C00-D49)
General guidelines
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.
Primary malignant neoplasms overlapping site boundaries
Malignant neoplasm of ectopic tissue
The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. For example, if the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.
See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.
a. 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 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.
b. 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.
c. Coding and sequencing of complications
Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:
1) 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).
2) 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.
3) Management of dehydration due to the malignancy
When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
4) 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.
d. 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, a code from category Z85, Personal history of primary and secondary 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 with the Z85 code used as a secondary code.
e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy
1) 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.
2) 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 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.
3) Patient admitted for radiation therapy, chemotherapy or immunotherapy and develops complications
When a patient is admitted for the purpose of 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.
f. 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.
g. Symptoms, signs, and abnormal findings listed in Chapter 18 associated with neoplasms
Symptoms, signs, and ill-defined conditions listed in Chapter 18 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first-listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.
See section I.C.21. Factors influencing health status and contact with health services, Encounter for prophylactic organ removal.
h. Admission/encounter for pain control/management
See Section I.C.6. for information on coding admission/encounter for pain control/management.
i. 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.
j. 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.
k. Malignant neoplasm without specification of site
Code C80.1, Malignant 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.
l. Sequencing of neoplasm codes
1) 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.
2) 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.
3) Malignant neoplasm in a pregnant patient
When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.
4) Encounter for complication associated with a neoplasm
When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.
The exception to this guideline is anemia. When the 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 code D63.0, Anemia in neoplastic disease.
5) Complication from surgical procedure for treatment of a neoplasm
When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.
6) Pathologic fracture due to a neoplasm
When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm.
If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture. The “code also” note at M84.5 provides this sequencing instruction.
m. Current malignancy versus personal history of malignancy
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of primary and secondary malignant neoplasm, should be used to indicate the former site of the malignancy.
See Section I.C.21. Factors influencing health status and contact with health services, History (of)
n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history
The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues. If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried.
See Section I.C.21. Factors influencing health status and contact with health services, History (of)
o. Aftercare following surgery for neoplasm
See Section I.C.21. Factors influencing health status and contact with health services, Aftercare
p. Follow-up care for completed treatment of a malignancy
See Section I.C.21. Factors influencing health status and contact with health services, Follow-up
There are Z code categories for aftercare following surgery for a neoplasm and for follow-up care after treatment of a malignancy. Many of these services are performed in the outpatient setting. Aftercare codes are generally listed first and explain the reason for the encounter. Aftercare codes are used following the initial treatment of a disease when the patient requires continued care during the healing and recovery stages or because of the long-term effects of the disease.
Even after a patient has been successfully treated for a malignancy, periodic, routine follow-up examinations may be necessary to determine if there has been any recurrence of the cancer. When there is no evidence of any type of recurrence, a code from the Z08 follow-up examination should be assigned. A Z code to identify the history of a neoplasm should also be assigned to show the reason for the follow-up examination. There is an instructional note to identify any acquired absence of organs. If there is any evidence of recurrence at the primary site and/or metastasis to a secondary site, the appropriate neoplasm code(s) are assigned.
q. Prophylactic organ removal for prevention of malignancy
See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal
r. Malignant neoplasm associated with transplanted organ
A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category T86.-, Complications of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.
6. Chapter 6: Diseases of Nervous System and Sense Organs (G00-G99)
5) 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).
When a patient has pain due to a previously identified neoplasm, code G89.3 is assigned. This code can be assigned as either principal or secondary, depending on the circumstances of the admission.
If a patient is admitted for pain management or pain control, the G89.3 code is assigned as the principal diagnosis, and the malignancy code(s) is assigned as a secondary code(s).
If a patient is admitted for management of the malignancy and the pain associated with the malignancy, the malignancy code is assigned as the principal diagnosis with the G89.3 pain code assigned as a secondary diagnosis.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
Anatomy and Physiology
Neoplasms can affect any of the body systems. The anatomy and physiology of these body systems are outlined in their respective chapters. It is important to understand some of the terminology that is specific to neoplasms and their behavior. According to the National Cancer Institute, the most common cancers in the United States include the following:
A neoplasm is an abnormal tissue that grows by cellular proliferation more rapidly than normal tissue. Neoplasms show partial or complete lack of structural organization and functional coordination with normal tissue, and they usually form a distinct mass of tissue that may be benign (benign tumor) or malignant (cancer) (Figure 10-1). Both benign and malignant neoplasms are classified according to the type of tissue in which they are found. Benign neoplasms are tumors that are not malignant. Malignancy is a neoplasm that has the ability to invade adjacent structures and spread to distant sites. Fibromas are benign neoplasms of fibrous connective tissue, and melanomas are malignant changes of melanin cells. Malignant tumors originating from epithelial tissue (e.g., skin, bronchi, stomach) are called carcinomas (Table 10-1). Malignancies of epithelial glandular tissue such as those found in the breast, prostate, and colon are known as adenocarcinomas. Malignant growths of connective tissue (e.g., muscle, cartilage, bone) are called sarcomas (Table 10-2). Lymphomas form in lymphatic tissue, and leukemias are malignancies that arise from white blood cells. A myeloma originates within the bone marrow.
TABLE 10-1
CARCINOMA AND THE EPITHELIAL TISSUES FROM WHICH THEY DERIVE1
| Types of Epithelial Tissue | Malignant Tumor (Carcinoma) |
| Gastrointestinal Tract | |
| Colon | Adenocarcinoma of the colon |
| Esophagus | Esophageal carcinoma |
| Liver | Hepatocellular carcinoma (hepatoma) |
| Stomach | Gastric adenocarcinoma |
| Glandular Tissue | |
| Adrenal glands | Carcinoma of the adrenals |
| Breast | Carcinoma of the breast |
| Pancreas | Carcinoma of the pancreas (pancreatic adenocarcinoma) |
| Prostate | Carcinoma of the prostate |
| Thyroid | Carcinoma of the thyroid |
| Kidney and Bladder | |
| Renal cell carcinoma (hypernephroma) | |
| Transitional cell carcinoma of the bladder | |
| Lung | |
| Adenocarcinoma (bronchioloalveolar) | |
| Large cell carcinoma | |
| Small (oat) cell carcinoma | |
| Squamous cell (epidermoid) | |
| Reproductive Organs | |
| Adenocarcinoma of the uterus | |
| Carcinoma of the penis | |
| Choriocarcinoma of the uterus or testes | |
| Cystadenocarcinoma (mucinous or serous) of the ovaries | |
| Seminoma and embryonal cell carcinoma (testes) | |
| Squamous cell (epidermoid) carcinoma of the vagina or cervix | |
| Skin | |
| Basal cell layer | Basal cell carcinoma |
| Melanocyte | Malignant melanoma |
| Squamous cell layer | Squamous cell carcinoma |
TABLE 10-2
SARCOMAS AND THE CONNECTIVE TISSUES FROM WHICH THEY DERIVE2
| Types of Connective Tissue | Malignant Tumor |
| Bone | |
| Osteosarcoma (osteogenic sarcoma) | |
| Ewing’s sarcoma | |
| Muscle | |
| Smooth (visceral) muscle | Leiomyosarcoma |
| Striated (skeletal) muscle | Rhabdomyosarcoma |
| Cartilage | |
| Chondrosarcoma | |
| Fat | |
| Liposarcoma | |
| Fibrous Tissue | |
| Fibrosarcoma | |
| Blood Vessel Tissue | |
| Angiosarcoma | |
| Blood-Forming Tissue | |
| All leukocytes | Leukemias |
| Lymphocytes | Hodgkin’s disease |
| Plasma cells | Non-Hodgkin’s lymphoma |
| Burkitt’s lymphoma | |
| Multiple myeloma | |
| Nerve Tissue | |
| Embryonic nerve tissue | Neuroblastoma |
| Glial tissue | Astrocytoma (tumors of glial cells, called “astrocytes”) |
| Glioblastoma multiforme |
The primary site is the location at which the neoplasm begins, or originates. It is important for the treating physician to identify the site of origin so that the best treatment course and prognosis can be determined. Metastasis is the spread of cancer from one part of the body to another, as is seen when neoplasms occur in parts of the body separate from the site of the primary tumor. Metastasis occurs through dissemination of tumor cells by the lymphatics or blood vessels, or by direct extension through serous cavities or other spaces.
Grading involves pathologic examination of tumor cells. The degree of abnormality of cells determines the grade of cancer (Table 10-3). When the level of cell abnormality is greater, the cancer is of higher grade. Cells that are well-differentiated closely resemble mature, specialized cells. Tumor cells that are undifferentiated are highly abnormal (i.e., immature and primitive).
TABLE 10-3
| Grade 1 | Cells slightly abnormal and well-differentiated |
| Grade 2 | Cells more abnormal and moderately differentiated |
| Grade 3 | Cells very abnormal and poorly differentiated |
| Grade 4 | Cells immature and undifferentiated |
Cancerous tissue is classified according to degree of malignancy, from grade 1—barely malignant—to grade 4—highly malignant. In practice, it is not always possible for the pathologist to determine the degree of malignancy, and sometimes it may be difficult even to determine whether a particular tumor tissue is benign or malignant.
Staging, a means of categorizing a particular cancer, helps the clinician to determine a particular patient’s treatment plan and the need for further therapy. Each type of cancer is staged according to specific characteristics:
In situ cancers have been diagnosed at the earliest possible stage.
Stage I or “local” cancers have been diagnosed early and have not spread.
Stage II has spread into surrounding tissues but not beyond the location of origin.
Stage III or “regional” cancer has spread to nearby lymph nodes.
See Table 10-4 for an example of how the TNM (tumor-node-metastasis) staging system would be used to classify a lung cancer.
TABLE 10-4
INTERNATIONAL TNM STAGING SYSTEMS FOR LUNG CANCER3
| Stage | TNM Description | 5-Year Survival, % |
| I | T1-T2, N0, M0 | 60-80 |
| II | T1-T2, N1, M0 | 25-50 |
| IIIA | T3, N0-N1, M0 | 25-40 |
| IIIB | T1-T3, N2, M0 | 10-30 |
| IV | Any T4 or N3, M0 | <5 |
| Any M1 | <5 | |
| Primary Tumor (T) | ||
| T1 | Tumor <3 cm in diameter | |
| T2 | Tumor <3 cm in diameter or with associated atelectasis–obstructive pneumonitis extending to the hilar region | |
| T3 | Tumor with direct extension into the chest wall, diaphragm, mediastinum, pleura, or pericardium | |
| T4 | Tumor invades the mediastinum, or presence of a malignant pleural effusion | |
| Regional Lymph Nodes (N) | ||
| N0 | No node involvement | |
| N1 | Metastasis to lymph nodes in the peribronchial and ipsilateral (same side as the primary tumor) hilar regions | |
| N2 | Metastasis to ipsilateral hilar and subcarinal (under the bifurcation of the trachea into the lungs) lymph nodes | |
| N3 | Metastasis to contralateral mediastinal or hilar nodes or any nodes new to the clavicular (collar) bone | |
| Distance Metastasis (M) | ||
| M0 | No known metastasis | |
| M1 | Distant metastasis present with site specified (e.g., brain, tumor) | |
Neoplasm Table
The coding of most neoplasms requires an extra step, which involves use of the Neoplasm Table (Figure 10-2). The main term for the type of neoplasm is located in the Alphabetic Index. All subterms must be reviewed to facilitate assignment of proper codes. One must follow all instructions, such as see Neoplasm, by site, benign, or see Neoplasm, by site, malignant. It is important to follow all steps to ensure correct code assignment. The temptation to go directly to the Neoplasm Table should be avoided.
In the following examples, a step-by-step explanation will be given for coding of neoplasms.
Example
Basal cell carcinoma left cheek (primary site) (Figure 10-3).
1. Look up “Carcinoma” in Alphabetic Index.
2. Review subterms; “basal cell” is a subterm.
3. Follow instructions to see also Neoplasm, skin, malignant.
5. Locate the site—skin—and review subterms under “skin.”
Exercise 10-1
Assign codes to the following conditions.
| 1. Malignant melanoma, skin left foot | _______________ |
| 2. Leukemia | _______________ |
| 3. Adenoma of the prostate | _______________ |
| 4. Renal cell carcinoma, right | _______________ |
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