Our first exercise is Chapter 29.3 #1
Bronchial adenoma. I have a note here for you that the "adenoma" is the morphological
type of cancer we are working with and "bronchial" is the site of that
cancer. The first step in locating a code for a neoplasm is to refer to the
main term for the morphological type in the alphabetical index and then to
review the sub entries and for some types, a specific diagnosis is provided.
This is taken directly from the Coding handbook on page 446. I note the one
guideline that is applicable here. If the histological term is documented, in
this case that is the adenoma, 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. If you remember the Neoplasm Table has
malignant primary, malignant secondary, benign, in situ, those and undetermined, I
believe, is the last one. So we'll look at that in just a moment but just to be
aware that sometimes you will go directly to the Alphabetical Index. Other
times I go directly to the Neoplasm table. So with experience, you will know
in the case of adenomas, I've selected code D38.1. So now let's go to the
document camera and you can see here I have adenoma. We go down to bronchial
here we go D38.1 and you say that if the documentation had had cylindroid type
in it, then it tells you to go here so you're always going to be watching for
these 'See" notes, S-E-E so that you know where to go. In this case, it looks like
D38.1 is going to get us where we need to be. So let's go back in the Tabular and here
we are in the Tabular D388.1, Nneoplasm of uncertain behavior of the trachea, the
bronchus and the lung. Remember from previous lectures the (word) "and" in the
the Tabular, the "and" in the Tabular can be (read as) "or" so the
patient does not have to have cancer in all three of these sites. It could be
read trachea or bronchus or lung. In this case, our medical documentation
tells us that it was in the bronchus. The next exercise is Chapter 29.3 number six
Hodgkin's sarcoma. In this example, the sarcoma is the
morphological type and the Hodgkin's is a more specific name that describes this
specific type of sarcoma.When we go to the Alphabetical Index, you're going to
see sarcoma ,sub term "Hodgkins" and it refers us to lymphoma, Hodgkin's. So
when we look up the lymphoma word, I will show you what I mean in the
Alphabetical Index. If we look here at sarcoma and we go down to Hodgkins, see
here Hodgkin's, "See lymphoma, Hodgkin" so we're going to look up this term in our
Alphabetical Index . So in the Alphabetical Index, we look up "lymphoma"
the very bottom of this page and we're looking for, we're going to move up until
we find Hodgkins.
Here it is Hodgkin's and as you see there's so many sub classifications but the medical
record documentation that's in this particular exercise doesn't give us very
much specificity, so we're going to choose the less specific C81.9 and as
you remember this little box means additional characters are needed so
let's go to the Tabular and look up C81.9. In our Tabular here we are
C81.9 unspecified and if you go down we see all these possibilities but our
documentation didn't give us any sites at all, just unspecified, unspecified site
so the correct code in this example would be C81.90. Here's the next
example 29.4 number 3 adenocarcinoma of the rectum and the anus. 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
is appropriate. Coding guideline I.C.2. This is a general guideline, not a
chapter-specific guideline, doesn't look like. Okay so we're going to look up our
pathway of Adenoma, carcinoma adenocarcinoma and it's going to say "See
also neoplasm, malignant by site so in this case, instead of taking you to the
Alphabetical Index because I'm trusting that you're beginning to get the gist of
this just so we'll go straight to the Table of Neoplasms and our main term
will be "rectum" then it's going to be indented "with overlapping lesion" with
another indentation "anus or rectosigmoid junction". So let's go to the Table of
Neoplasm
Okay so we're in the Table of Neoplasms and you notice across the top, primary
malignant, secondary malignant, cancer in stitu, benign, uncertain and
unspecified behavior and we're going to look up "rectum" in this case so we're
going to go down here and I have put a marker to help me read my indentation
correctly. Rectum and colon, overlapping lesion with anus or rectosigmoid
junction C21.8 and we are in the malignant primary column, that first
column. So that's how we find it in the Table of Neoplasm and now we're
going to look up this code in the Tabular and when we get here we see "C21.8
malignant neoplasm of overlapping sites of rectum, anus and anal canal,
primary malignant neoplasm two or more contiguous sites, so this is our correct
code C21.8. Our next example is 29.5 number 3 metastatic carcinoma from the
prostate to the pelvic bone, previous prostatectomy with no recurrence at
primary site. I show you in a little note there in this example the prostate
cancer is malignant, primary; the pelvic bone cancer is malignant, secondary
however, because the prostate was already removed, we use the Z85-
category. The pelvic bone is the principal (diagnosis) and we have a guideline that
directly relates to this. Primary malignancy previously excised. I'll let
you read that for yourself. The Z85 code, personal history of malignant
neoplasm is used to indicate the former site of the malignancy and then the
table of neoplasm is where we would look up the pelvic bone cancer and find C79.51
I want to go to this table of neoplasms just to show you, remind
you again, be careful which column you're in so you read the right column.
So we're in the Table of Neoplasms, we have malignant primary, malignant secondary. We
know that this pelvic bone cancer is malignant, secondary so we're going to use
the second column. Go down. We're in bone, see here this is our primary term right
here. Come down we're looking for pelvic, pelvic second column C79.51 and when we
look up that code in their Tabular.It's a pretty general code, secondary malignant
neoplasm of bone so even though we had all those sub terms under bone, when it
comes to a secondary malignant it's fine to use a more general term so this is
the correct code for this exercise. The next example is 29.5 number 6 metastatic
carcinoma of the brain and the lung and using what we learn from our Coding
Handbook page 451, we know that there's no determination in this documentation as to
which is the primary site. so in this case we're going to use that C80.1 code
to indicate that. We don't know which one is primary. The lung cancer as
the primary because of that table that's in your Coding Handbook on page
451, it says "when the morphology type is not stated, the only code that can be
obtained is C80.0 or C80.1, code as a primary malignant neoplasm whatever
you're looking at, whatever site, unless the site is one of those listed on page 451.
The brain, as a site of cancer, is on that list on page 451 therefore the
brain cancer is going to be coded as secondary. In this example, I don't
believe it matters which code goes first because the information we've been
given doesn't tell us which one is the focus of treatment. I think it's such
a general statement and honestly, in the real world, I don't think you would see
this statement very often. I think the point the author's making is just trying
to get you to use the Coding Handbook and recognize that there is consensus
across the coding industry that certain sites are not coded as primary
unless they aren't on that list, kind of an exclusion list. Okay,
let's go to the next one. This is just where I show you... from the Table of
Neoplasm in our previous slide, we showed the brain as the malignant secondary
using that second column, the lung is our primary (malignancy) using that first column. It all
relates back to that table on page 451 in your Coding Handbook for why we allowed
the lung to be the primary and the brain to be the secondary. Back to this though
because we didn't know, we had to use this C80.1 code in addition to the
other two codes. Okay all right let's go to our next one. This is 29.8 number 15.
Patient admitted for chemotherapy following an oophorectomy on the previous
admission for carcinoma of the left ovary. If you don't remember your medical
terms, (the suffix) -ectomy usually means "cutting out" so an oophorectomy would be the
removal of the ovary. So she's had the removal of the ovary and she's there for
chemo so our principal diagnosis is going to be the encounter for the
chemotherapy. That is found in the Alphabetical Index under "encounte" with
the sub term "chemotherapy" for neoplasm. So let's look.We also have to code her
cancer and that is ovarian and it's primary malignant.I'll let you look it
up for yourself in the Table of Neoplasms and be mindful of a couple of
things here. There is a guideline very specific to an encounter solely for
chemo or immunotherapy or radiation therapy and it tells us if the patient is
being admitted soley for administration of one of those things, we are going to
assign the appropriate Z code which we just looked up, Z51.11 as our
principal diagnosis. There are guidelines, different guidelines whether the patient
is getting chemo, immunotherapy or radiation therapy and to also be aware
of this guideline, "current malignancy versus a personal history of malignancy".
We're going to use this primary malignancy code, her ovarian cancer until
her treatment is completed. Once that chemo or radiation or whatever treatment
is completed, then she would get that "history of personal malignancy" code but
until she gets all this treatment out of the way, you're going to code that cancer
as an additional code with the principal diagnosis being the encounter for chemo.