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Overcome challenges in selecting principal diagnosis when coding for neoplasm treatments

JustCoding News: Inpatient, July 7, 2010

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Proper principal diagnosis selection is critical to ensure that patient encounters are grouped under the proper MS-DRGs and facilities receive appropriate reimbursement. When coding for neoplasm treatments, however, coders need to be cognizant of specific ICD-9-CM coding and sequencing guidelines.

William Haik, MD, FCCP, highlighted four common neoplasm sequencing challenges of which coders should be aware during a March 29 HCPro audio conference “Principal Diagnosis Selection: Ensure MS-DRG Accuracy and Avoid Compliance Risk.”

Sequencing a malignant neoplasm

If a physician admits a patient to the hospital for treatment of a primary or secondary malignant neoplasm, the malignancy is the principal diagnosis, Haik said.

For example, if a physician admits a patient for resection of colon cancer, and a few days following the surgery during the same admission the patient undergoes the first cycle of chemotherapy, the principal diagnosis is colon cancer.

However, if the patient is discharged and the physician readmits that same patient two days later to receive chemotherapy, then the principal diagnosis for the new inpatient stay is the chemotherapy (code V58.11).

The ICD-9-CM Official Guidelines for Coding and Reporting state that the procedure code is the principal diagnosis when a physician admits a patient solely for chemotherapy (code V58.11), immunotherapy (code V58.12), or radiation therapy (code V58.0).

“To me, it seems a bit odd that you would have a procedure as a principal diagnosis,” Haik said during the audio conference, “but that’s the rule.”

Sequencing complications of malignant neoplasms

Sequencing complications of neoplasms is difficult because Coding Clinic did not issue clear coding rules, said Haik, who was a member of the Expert Advisory Panel for Coding Clinic for ICD-9-CM when the panel wrote the rule.

“We tried mightily to write some sequencing rules regarding neoplasms and we failed, actually” Haik said during the audio conference.

To help coders understand proper sequencing, Haik suggests that they think of complications in two groups: systemic and local.

When a physician admits a patient for a systemic complication of a malignancy and the complication is the only condition treated, then coders should select the complication as the principal diagnosis.

For example, when a physician admits a patient with inoperable bowel cancer for acute blood loss anemia and the patient receives a transfusion of four units of packed cells, the principal diagnosis is acute blood loss anemia, and the bowel cancer is an additional diagnosis.

However, when the physician admits a patient for a local complication due to a malignancy, then the neoplasm is the principal diagnosis.

Consider a case in which a physician admits a patient with obstruction of the ureter secondary to a metastasis from a previously resected colon carcinoma, and surgeons place a urinary stent to relieve the obstruction with no other therapy rendered for the metastasis. In this case, the principal diagnosis is the metastasis, and you would report the obstruction of the ureter as an additional diagnosis.

“You would normally think the ureteral obstruction, which is not a chapter 16 code, would be the principal diagnosis,” Haik said. “But it is a local complication of the carcinoma, and so the carcinoma is the principal [diagnosis].”

Coding for neoplasm-related signs and symptoms

When a physician admits a patient for signs and symptoms related to a neoplasm, assigning the principal diagnosis can get a little tricky. The ICD-9-CM Official Guidelines for Coding and Reporting state that coders cannot report signs and symptoms codes (chapter 16 codes in the ICD-9-CM Manual) as the principal diagnosis, Haik said.

So when a physician admits a patient with nausea and vomiting that is secondary to a previously diagnosed gastric carcinoma, the gastric carcinoma is the principal diagnosis.

However there is an exception to the rule.

In October 2006, CMS created a new neoplasm-related pain code (338.3). Although neoplasm related pain is a sign and symptom of the neoplasm, 338.3 is in chapter 6 of the ICD-9-CM Manual, therefore you can list it as a principal diagnosis

So when a physician admits a patient with abdominal pain secondary to a previously diagnosed gastric carcinoma and physicians determine that no other acute condition is causing the abdominal pain, then the neoplasm-related pain is the principal diagnosis.

Treatment of metastatic sites

When a physician admits a patient to treat a neoplasm that has metastasized to a secondary location, you should list the secondary site as the principal diagnosis, Haik said. This is true whether or not the primary site is present.

Consider a case in which a physician admits a patient for a bilateral orchiectomy for bone metastasis from carcinoma of the prostate. The principal diagnosis is the metastatic carcinoma of the bone because that site is the reason for this admission.

If the primary site is still present and under active treatment, list the primary site as an additional diagnosis. In this example, you would also list carcinoma of the prostate as an additional diagnosis.

If a physician previously excised the primary site, which he or she is no longer treating, then you should report a personal history of malignant neoplasm of the prostate (V10.46) as an additional diagnosis.

Editor’s note: E-mail questions to Managing Editor Doreen Bentley, CPC-A, at dbentley@hcpro.com.

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