Chapter 6 Flashcards
neoplasm
abnormal tissue growth; tumor
mass
abnormal collection of tissue
carcinoma
a malignant neoplasm or cancerous tumor
malignant
invasive and destructive characteristic of a neoplasm; possibly causing damage or death
-cancerous
benign
nonmalignant characteristic of a neoplasm; not infectious or spreading
-not cancerous
metastasize
to proliferate, reproduce, or spread
functional activity
glandular secretion in abnormal quantity
topography
the classification of neoplasms primarily by anatomical site
morphology
the study of the configuration or structure of living organisms
overlapping boundaries
multiple sites of carcinoma without identifiable borders
ectopic
out of place such as an organ or body part
List 4 Reasons why a patient might come in for a screening test
- calendar- such as an annual
- age- such as 50 years (colonoscopy)
- family history- such as mother had been diagnosed
- personal history- such as a patient had this before
When are diagnostic tests done?
- patient exhibits signs and symptoms of a condition
- test is needed to confirm or deny physician’s diagnostic suspicion
Neoplasms may be defined by and individual name. List some examples
- adenoma
- melanoma
- leukemia
- papilloma
What are different categories of tumors (4)?
- malignant
- benign
- carcinoma in situ
- uncertain
Carcinoma in situ
- encapsulated in a specific organ
- the believe to have removed it from said location
uncertain
pathologist has looked at the tissue and behavioral characteristics are uncertain (unclear)
Malignant Primary
indicates the anatomical site (the place in the body) where the malignant neoplasm was first seen and identified
Malignant Secondary
identifies the anatomical site to which the malignancy metastasized
When coding where do you find the codes that you need to report (2)?
neoplasm table
alphabetic index
What do you need to know to determine the code to report a neoplasm (3)?
- where in the body (specififically which anatomical site) is the neoplasm located?
- is the neoplasm benign, malignant, ca in situ, or uncertain?
- if the neoplasm is malignant, is the first diagnosis of malignancy for this patient?
- if so, this is the primary site
- if not, this is a secondary malignancy (metastasized from the primary site)
unspecified behavior
doctor has not specified if the neoplasm
- query the physician
Can you code right from the Neoplasm table without checking the tabular index?
yes
Can you use a pathology report when coding neoplasms? why?
yes.
a pathologist is a physician
When a pregnant woman is diagnosed with a malignancy, how might you code that?
a code from code subcategory O9A.1-Malignant neoplasm complicating pregnancy, childbirth and the puerperium will be reported as the principal diagnosis, followed by the code for the primary malignancy
Is a patient in remission and a patient with a personal history of the same thing?
No.
If the documentation is not absolutely clear on this, you must query the physician for clarification.
Functional Activity (important chapter notes)
“All neoplasms are classified in this chapter, whether they are functionally active or not. An additional code from chapter 4 may be used to identify such functional activity associated with any neoplasm.”
Morphology (histology)
important chapter notes
“Chapter 2 classifies neoplasms primarily by site (topography) with broad groupings for behavior, malignant, in situ, benign, ect. The Table of Neoplasms should be used to identify the correct topography code. In a few cases such as for malignant melanoma and certain neuroendocrine tumors, the morphology (histologic type) is included in the category codes
Primary Malignant Neoplasms Overlapping Site Boundaries
“A primary malignant neoplasm that overlaps two or more contiguous (next to each other)sites should be classified to the subcategory/code 8 (“overlapping lesion”), unless combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.”
Malignant Neoplasm of Ectopic Tissue
important chapter notes
“Malignant neoplasms of ectopic tissue are to be coded to the site mentioned, e.g. ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9)
If the encounter is only for therapeutic treatment of a malignancy, such as the administration of Chemotherapy, immunotherapy, or radiation therapy, What will the principle (first-listed) code be? What will it be followed by?
Principle code will report the therapeutic treatment of a malignancy
followed by a code or codes to report the details about the malignancy being treated.
After a surgical procedure to remove the malignancy, the patient no longer has the anatomical site where the malignancy was located. Therefore, the patient can no longer have that condition.
How is the code we report affected?
Thereafter, the code will change from a malignancy code (C00-C96) to a personal history of a malignancy code (category Z85)
If a patient is admitted for treatment of anemia manifested from malignancy, and only the anemia is treated during this stay. How would you code this?
Report the code for the neoplasm as the principle diagnosis FOLLOWED by code D63.0 Anemia in neoplastic disease
If a patient is admitted for treatment of dehydration manifested from malignancy, and only the dehydration is treated during this stay, How would you code this?
Report the code for the dehydration as the principle diagnosis followed by the code for the neoplasm that was the reason the treatment was needed.
Admission for radiation, chemotherapy, or immunotherapy, develops complications during the encounter, how would you code this?
(Complications of treatment)
Report Z51.0, Z51.11, or Z51.12 as the principal diagnosis code FOLLOWED by the code (S) to report the specific complications
Admission for treatment of Anemia resulting from chemotherapy or immunotherapy- how would you code this?
Complications of treatment
report a code for the anemia first, FOLLOWED by adverse effect code
Admission for treatment of anemia resulting from radiation treatments- how would you code this?
Complications of treatment
report a code for the anemia first, followed by neoplasm code, followed by Y84.2
In the Treatment of the Secondary Site Only, how would you report this?
report the secondary site as the principle diagnosis followed by the primary site malignancy code
