CDI Adult MDC 3 - ENT

Question 1

Official Guidelines: Neoplasms
* If the focus of treatment is the primary neoplasm, what will be assigned as the Principal Diagnosis?
* If the focus of treatment is the secondary site, what will be assigned as the Principal Diagnosis?

Answer 1

• If the focus of treatment is the primary neoplasm, assign the primary neoplasm as the principal diagnosis.
• If the focus of treatment is the secondary site, even if the primary site is still present, assign the secondary neoplasm as the principal diagnosis.

C. Chapter-Specific Coding Guidelines
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 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.

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.