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Neoplasm Coding Flashcards

1
Q

Extra nodal lymphoma

A

Code to: C88.4~
Extranodal marginal zone b-cell lymphoma of mucosa- associated tissue.

** Do not confuse lymph node malignancies with lymphomas**

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2
Q

Secondary extranodal lymphoma

A

Code to: c77~

  • Secondary and unspecified malignant neoplasms of lymph nodes*
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3
Q

Lymphoma

A

HL - lead term (Hodgkin)

NHL - lead term (lymphoma)

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4
Q

Leukemia

A

Code range:
C91.^ - C95.^

Classified according to stem cell type:
- Lymphoid
- Myeloid
- Monocytic

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5
Q

Admission for diagnostic investigation

A

If diagnosis made and then diagnosis is mrdx

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6
Q

Admission for surgery following excisional biopsy

A

Code describing malignancy as mrdx

Code this way even if pathology report is negative because malignancy was the reason for excision

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7
Q

Admission solely for radiotherapy or chemotherapy

A

Z51.0~ * radiotherapy*
Z51.1~ * chemotherapy*

+ Code for primary malignancy as additional mandatory code

  • DX type 3/OP
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8
Q

Radiotherapy or chemotherapy during admission for surgical removal of tumor

A

** do not assign Z51 codes **

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9
Q

Administration of pharmaceuticals or radiotherapy for neoplasia

A

** mandatory to assign CCI code**
1.ZZ . 35.^^~ * PHARMACOTHERAPY TOTAL BODY*
- - qualifier M9 if combination agents used

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10
Q

Admission for pre-treatment assessment to initiate chemotherapy

A

Z01.8~ * other specified special examination*
- code as mrdx/mp

+ Code for malignancy as type 3

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11
Q

Admission for mid-treatment assessment

A

Z51.88~ * other specified medical care*

Note:
If patient finds out they need chemo during investigation then it would be mid-treatment

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12
Q

Admission for brachytherapy

A

Assign code for malignancy as mrdx

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13
Q

Admission for complications of malignancy

A

If admitted for treatment of complication then complication assigned mrdx

Also code neoplasm determine diagnosis typing

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14
Q

Admission for follow-up with no residual or recurring tumor found

A

Often described as recheck or surveillance

Z08^~ .* Follow up examination after treatment for malignant neoplasm* code as mrdx

Z85.^~ * personal history* type 3
- mandatory to assign for breast lung and prostate cancer

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15
Q

Admission for follow-up with residual or recurring tumor found

A

Tumor coded as mrdx
Assign:

Z08.^~ * follow up after treatment for malignant neoplasm*

Z85.^~ * personal history*
- DX type 3/op
- ** mandatory to assign**

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16
Q

Previous mastectomy lobectomy or pneumonectomy and currently undergoing another excision of contralateral side for new primary malignancy

A

Mandatory to assign:
Z90.1^/ Z90.2^
* Acquired absence of breast/ lung*

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17
Q

Admission** solely** for palliative care

A

Z51.5~ * palliative care* mrdx

+ Neoplasm
- mandatory
- DX type 3

18
Q

Personal history of chemotherapy

A

Z92.6~ * personal history of chemotherapy*
- binocular #4
- optional, DX type 3

19
Q

When malignancy ruled out after some sort of testing during episode of care

A

Z03.1~ * observation for suspected malignant neoplasm*

For example: biopsy proves negative for malignancy, negative, PSA or ca125 test

20
Q

Patient undergoing prophylactic surgery no cancer present

A

Z40.^~ prophylactic surgery*
- mrdx/mp for patients

  • assign Z85.^ if performed due to personal history of breast prostate or lung neoplasm
  • assign code to identify reason for prophylactic surgery when part of treatment protocol for current malignancy
    • e.g. orchidectomy and prostate cancer
21
Q

No recognize symptoms but are considered at risk for use of certain types of prostate cancer. ** No malignancy found **

A

Z12.^~ * special screening for malignant neoplasm*

22
Q

skin rule

A

When you encounter # code to skin of site.

If morphology is squamous cell carcinoma or epidermoid carcinoma

23
Q

Bone rule

A

Only code as primary neoplasm of bone if:

  • intraosseous carcinoma/ adenocarcinoma
  • odontogenic carcinoma/adenocarcinoma

** All other secondary unless stated. Otherwise**

24
Q

Connective tissue rule

A

When the morphological type indicates connective tissue then connective tissue becomes the first anatomical site

For sites that do not appear in the list, go to neoplasm of those sites

25
Contiguous sites
** within same three character category:** Fourth character of 8 to characterize malignant neoplasms that overlap** unless indexed elsewhere* ** Within separate three character category** - refer to list at beginning of neoplasm chapter - - note these codes are not included in alphabetical index. Therefore important to know this rule
26
Residual categories
Fourth character 7. To classify other sites not elsewhere classified -** use only after confirming there is no other more specific code. ** Fourth character 9. Assigned to categorize unspecified sites - used only after confirming more specific documentation /information not available
27
Malignant neoplasms of esophagus
Two alternative subclassifications are given: .0 to .2: anatomical sites .3 to .5: thirds of esophagus ** Select according to documentation**
28
Functional activity
When patient is admitted for the management of: -** functional activity** of a tumor ( functional disorder) or paraneoplastic syndrome ** And** - no treatment is directed to neoplasm itself Then: Code for the disorder of the functional activity as the mrdx/mp ** and** assign code for neoplasm as type 3/op
29
Multiple independent primary malignant tumors
Code each independent primary malignant tumor (same organ or not) separately Optional to assign c97~ * malignant neoplasm of independent (primary) multiple sites - DX type 3/op
30
Recurrent malignant neoplasm
New primary lesion in same site as previously. Excised/ eradicated site ** mandatory to assign** Z85.^~ personal history of malignant neoplasm - DX type 3/op ** Does not require clustering**
31
Refractory cancer
Use additional code u85~ *resistant to antineoplastic drugs* -Mandatory to assign - - type 3/op
32
Secondary (metastatic) malignant neoplasms
Always assign code for the secondary neoplasm Always assign a code for the primary site - if still present, select a code from chapter 2 - if eradicated assigned z85.^~ * personal history of malignant neoplasm* ** Important** local invasion into adjacent tissue different than secondary. If this is the case, simply assigned to point of origin Refer to standard PDF page 165 for more details
33
Ambiguous terminology, metastatic and metastases
Site could be primary or secondary Follow who guidelines - metastatic to and metastatic from are self-explanatory - metastatic and metastatic of considered unclear - if common sites of metastases assume secondary?
34
Metastatic neoplasm primary site unknown
Primary site documented as unknown c80.0 * malignant neoplasm primary site unknown* When no documentation regarding primary site exists: Assigned c80.9* malignant neoplasm unspecified*
35
Ambiguous terminology two sites listed
Both sites assumed secondary metastatic cancer of lung and bone
36
Ambiguous terminology one site mentioned
Single site mentioned ambiguously such as metastatic renal cell CA lung - review morphological type
37
Ambiguous terminology no morphological information available
Classify site described as metastatic to primary sites** unless** listed as a common site of metastases: Bone Brain Diaphragm Heart Liver Lung Lymph nodes Mediastinum Meninges Peritoneum Pleura Retroperitoneum Spinal cord
38
Common sites of metastases:
Bone Brain Diaphragm Heart Liver Lung Lymph nodes Mediastinum Meninges Peritoneum Pleura Retroperitoneum Spinal cord
39
Unspecified site of malignancy
Disseminated or carcinamatosis refers to spread of cancer to multiple secondary sites - code each primary and secondary site when known Unspecified secondary code c79.9 Unspecified primary code c80.9 Unknown primary code c80.0
40
Equal treatment to primary and secondary sites
Primary sequenced first as mrdx or type 1/op Secondary as DX type 1 or op
41
Treatment directed to secondary sites alone
Sequence secondary site first as mrdx /mp or type 1/op Primary site DX type 3/op -- chapter 2 code? ** Or ** Z85.^ * personal history of malignant neoplasm* DX type 3/op always - only use if malignancy completely eradicated and no further treatment, including adjuvant therapy is directed toward primary site
42
Personal history code mandatory when?
- For current malignancy at same organ/ tissue (recurrent malignancy) - Previously eradicate primary site when there is secondary - when there is a history of malignant neoplasm of: Breast Prostate Lung Use z85 code DX. Type 3/op

Coding (8 decks)

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