Good morning.Today we're going to look at the Chapter 2 coding guidelines and I
have a note here that there weren't any changes in 2017 for Chapter 2 so in
this regard, you could just look at your code book and the guidelines there and
not have to worry about anything additional being added. I'm still going to go over
some of the guidelines, not all of them, just so you have an idea of how they
might be applied. Alright, let's get started. The first guideline has to do
with treatment directed at the malignancy. You're going to see as
you move through some of these guidelines, there's treatment directed at
primary malignancies; there's treatment directed at secondary malignancies which
are malignancies which have metastasized from the primary site; and those
treatments directed at complications of the malignancy like anemia or
dehydration or complications of surgery. Where the treatment is directed is
how you know which guideline you're going to apply. In this case, the
treatment is directed at the primary malignancy. That is right here in the
diagnostic statement.
We have here the codes for you and the index pathway that shows
you what I looked up. Malignancy(main term) it took me to the Neoplasm Table. You will
almost always start with the Table of Neoplasms if your malignancy is
specified but if words like adenoma are used, then you have to
start in the (Alphabetical Index to find your terms. Also leukemia is in the Index, much
easier to find it there than it is in the Table of Neoplasms but in this case
this patient has stomach cancer primary that has spread to the
retroperitoneum and the peritoneum. So you see that in the Table of Neoplasms, I'm
in the Malignant, primary column to find the code for the stomach cancer and then
I'm in the Malignant, secondary column to find the codes for retroperitoneum and
peritoneum. Now because those two terms. retroperitoneum and peritoneum have the
same code, you're only going to use that code once. All of that just to say or
give you an example of a guideline when the treatment is directed at the primary
malignancy. The next guideline has to do with treatment of a secondary site.This
is when the cancer has metastasized or moved to another site. In this scenario,
the patient's admitted to the hospital for treatment of right lung cancer which has
metastasized from the prostate. So the prostate was your primary cancer and the
right lung is the malignant secondary. So when you go to the Table of Neoplasms,
you're going to look up those neoplasms, taking note that the lung cancer is in
the malignant secondary (column) and the prostate is a malignant primary (column). The- dash there (-),
after the C78.0- tells you that additional characters are needed. For
example, the additional character "1" is needed to
identify the right lung.
This guideline has to do with anemia associated with the malignancy. Anemia
can be associated with different things and in this case, it is specifically
associated with the malignancy and a guideline tells us that when the
admission is for management of anemia associated with the malignancy and the
treatment is only for the anemia, the malignancy is coded first and then the
anemia. So I have here the Table of Neoplasms showing you the colon cancer.
It's the malignant primary and then the anemia is your main term in the (Alphabetical) index,
with or due to neoplastic disease. (The terms) neoplastic disease, neoplasm and
malignancy are all terms that can be used interchangeably. I mentioned earlier
that anemia can be associated with many different things. The anemia in this
example is associated with the chemo, immuno- and radiation therapy.It's not
uncommon for these therapies to knock out red blood cells in the bone marrow
so that the patient then becomes anemic and that is specifically related to the
administration of these drugs or radiation. Our guideline is if the anemia
associated with these therapies is being treated and it's the only thing being
treated, then the anemia is sequenced first followed by the code for the
cancer. The adverse effect code, which is T45.1X5, you
see that I have a note there that the adverse effect associated with radiation
is a different code. So you just have to go back to your guidelines to read about that.
You see in that T45 code, there are seven characters. That "A" at the end of that
code has to do with the initial encounter. This is an initial encounter.
In the case of chemo, immuno and radiation is going to stay a "A".
Because it's an initial encounter, as long as treatment is being delivered for
a condition. So in that case I can't think of a good example where you would
use the "S" or the "D" (7th characters); they probably are there but for this case, when you look at
an initial encounter, that's how you know what to use. This guideline has to do with the
management of dehydration due to a malignancy and the admission is solely
for the treatment of the dehydration. You're going to code the dehydration first
and then the malignancy. You see where the guidelines come into play here
because normally you might think you would code the cancer first because
that's the reason why the person is having these problems but we have to
always code using the guidelines. Unless you're going to follow a
guideline, you might incorrectly put the cancer code first and this guideline is
saying no, if a patient's being admitted just for the dehydration, even though
it's due to the cancer, you're going to code the dehydration first, Your
sequencing directions are given in that guideline.This guideline has to do with
previous excision of a malignancy. Say the patient here has a history of breast
cancer and had a radical mastectomy on the left (breast) two years ago, has no current
treatment but bronchoscopy has shown that the original breast cancer has
metastasized to her lung. So the lung would be your secondary malignant cancer.
The breast cancer (history) would be coded as Z85.3. The breast cancer would be coded as a
personal history of breast cancer because she had a mastectomy
and is getting no current treatment.So the Z85.3 just tells the
reader she had cancer in the breast but she no longer has that.
The secondary cancer would still be coded and it would be first
because this is what she's being admitted for. This guideline has to do with
admissions solely for the administration of therapy and you see the case I've
given you.The patient was giving immunotherapy and chemotherapy for
treatment of blood cell lymphocytic leukemia and I have a
rationale there for how you would code that. You could sequence either one of
those first as the guidelines tell us but you would add the Leukemia
or the malignancy code in addition to the two chemotherapy and immunotherapy
codes.This guideline has to do with cancer in a pregnant patient. I've given
you an example here. We always would use that O9A.11- and then
your sixth character in this case is your trimester.The number "2" indicates
the second trimester.Then I'm giving you there the guideline. This guideline
has to do with the pathological fracture due to a neoplasm and the patient's being
treated for the fracture. You would code the M84 category code. The pathological
fracture would be your first code and then the cancer would be your second
code.This is true because the focus of treatment is the fracture. If the focus
of treatment had been the neoplasm and the patient just happened to have a
pathological fracture. then the cancer would be sequenced first and then the
M84 category code.
Current malignancy versus a personal history (of malignancy). You see here the patient is
undergoing chemo after a right mastectomy two weeks ago. Even though the
breast has been removed. as long as she's receiving active treatment, we will code
the breast cancer.So I've coded the breast cancer here. There is your Table
of Neoplasm. I also coded the absence of breast to
signify that she has had the mastectomy on the right. This has to do with
malignant neoplasm associated with a transplanted organ. The patient has cancer of
the right kidney and that right kidney was transplanted last year. So you're
going to use the T86 category code to signify the complication of the kidney
transplant. You're also going to use the C80.2 code. per your guideline.
which is specific to a malignant neoplasm associated with a transplanted
organ. Last of all, you're going to add the kidney cancer. So you have all
three codes and they would be sequenced in this order. If you have any questions
about the guidelines, please post them in discussion board. If you have a specific
scenario you want to discuss, please tell me which path you can use to try and
find it. The next several slides have to do with the screen shots that have been taken
from this book. They're here. I'm not going to go through them but they are
here, if it's helpful to you. I will not be doing this in future podcasts but
just to give you an idea of this book and if you're interested in it, I
encourage you to buy it. Okay that's it for today. Have a good week.