Chapter 6 - Coding Neoplasms Flashcards
Terminology
Neoplasm
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Abnormal tissue growth; tumor.
Mass
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Abnormal collection of tissue.
Carcinoma
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A malignant neoplasm or cancerous tumor.
Malignant
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Invasive and destructive characteristic of a neoplasm; possibly causing damage or death.
Benign
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Nonmalignant characteristic of a neoplasm, not infectious or spreading.
Malignant primary means:
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The term primary indicates the anatomical site (the place in the body) where the malignant neoplasm was first seen and identified.
Malignant secondary means:
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The term secondary identifies the anatomical site to which the malignancy metastasized.
Metastasize
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To proliferate, reproduce, or spread.
Ca in situ
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The term Ca in situ indicates that the tumor has undergone malignant changes but is still limited to the site where it originated, for example it has not spread.
•Ca is short for carcinoma
• situ as in the word situated.
So think of it as a cancerous tumor that is staying in place.
Uncertain
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The classification uncertain indicates that the pathologist is not able to specifically determine whether a tumor is benign or malignant because indicators of both are present.
Unspecified Behavior
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Choose codes that describe “unspecified behavior” when the physician’s notes do not include any specific information regarding the nature of the tumor. Before choosing one of these codes please query the Physician and make certain that a laboratory report is not available or on its way with the information you need.
Some common tests are performed when various types of malignancies are suspected; Malignant Neoplasm of the Cervix:
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- Abdominal Ultrasound
- Cervical Biopsy
- Colposcopy
- CT scan of the abdomen and pelvis
Some common tests are performed when various types of malignancies are suspected; Malignant Neoplasm of the Colon and Rectum:
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- Barium Enema
- Carcinoembryonic Antigen (CEA)
- Colonoscopy
- Stool for Occult Blood
Some common tests are performed when various types of malignancies are suspected; Luekemia / Lymphoma:
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- Blood Smear
- Bone Marrow Biopsy
- Cell surface immunophenotyping
- Cryoglobulins
Some common tests are performed when various types of malignancies are suspected; Malignant Neoplasm of the Lung:
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- Alpha- 1 antitrypsin
- Bone Scan
- Bronchoscopy
- Chest x-ray
- Lung Biopsy
Some common tests are performed when various types of malignancies are suspected; Malignant Neoplasm of the Ovary:
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- CA- 125
- Laparoscopy
- paracentesis
- Pyelography
Some common tests are performed when various types of malignancies are suspected; Malignant Neoplasm of the Prostate:
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- Acid Phosphatase
- CT scan of the pelvis
- Cystoscopy
- MRI of the Prostate
- Prostate Specific Antigen (PSA)
The 4 Cancer Stages
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- Stage 0 - abnormal cells are present but have not spread to the nearby tissue. Also known as carcinoma in situ, or CIS. CIS is not malignant, but it may evolve into malignancy.
- Stage I, II, III - malignant cells are present. The higher the number, the larger the malignant tumor and the more it has metastasized to nearby tissues.
- Stage IV - malignant cells have metastasized to distant parts of the body.
Neoplasms might be malignant or benign or have aspects of both characteristics. In diagnoses, neoplasms may also be defined by an individual name:
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- Adenoma
- Melanoma
- Leukemia
- Papilloma
In medical terminology, the suffix - oma means:
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tumor.
Functional activity
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Glandular secretion in abnormal quantity.
Topography
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The classification of neoplasms primarily by anatomical site.
Morphology
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The study of configuration or structure of living organisms.
Overlapping boundaries, (also known as contiguous, may blur anatomical descriptors)
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Multiple sites of carcinoma without identifiable borders.
Ectopic
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Out of place, such as an organ or body part.
• outside of an organ. Therefore, if the diagnostic statement describes the tumor as being ectopic, report the condition to the nearest, identified organ.
Leukocytosis
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Blood test result indicating an increased white blood cell count (WBC).
Pathology Reports
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- Histopathology
- Tissue Biopsy Culture
- Lumbar Puncture
- Blood Culture
- Labs
Histopathology Report
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A punch biopsy of the overlying skin.
(Example Result: Reveals in adenocarcinoma with diffuse involvement of the dermis and extensive invasion of the dermal lymphatics. The adenocarcinoma is composed of irregular nests with some areas forming tubercles. Mitotic figures, including atypical forms, are seen. The tumor was ER -, PR -, Her2 +, CK7 +, and CK 20 -.)
Tissue biopsy culture
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(Example Result: Negative for any growth.)
Lumbar puncture
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(Example Result: negative for organisms.)
Blood culture
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(Example Result: 2/2 positive for Neisseria meningitis.)
Labs
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Example Result:
WBC: 8.6 Hgb/Hct: 9.4/26.3 Platelets: 222 BUN: 71 Creatinine: 6.8 U/A: 2+ Protein, 3+ blood ANA: negative Hepatitis B surface antigen: negative Hepatitis C antibody: negative Serum Cryoglobulins: negative HIV: negative cANCA: positive (1:1280) Tissue culture: negative Initial blood cultures: negative CXR: bilateral opacities
Specimens may be provided to the laboratory in various forms:
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- Blood (capillary or vein)
- Urine
- Semen
- Sputum
- Swabs (that carry tissue cells, pus, or other excretion)
- Tissue Specimens (Surgical samples taken during a biopsy)
The terms that indicate the malignancy has infiltrated the body throughout and affects all or most of the patient’s Anatomy:
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- Disseminated cancer
- Generalized cancer
- Widely metastatic
