Revenue Cycle

Go Pink for Breast Cancer Awareness Month

Coding Educator, October 19, 2009

By Jennifer Avery, CCS, CPC, CPC-H CPC-I
 
Breast cancer is a personal issue for me. There are several members of my family who have either had breast cancer or suffer from fibroids and I have to go for routine mammograms each year due to my own past personal history of Fibrocystic Breast Disease and strong family history. When I turned 18 I was promoted from screening to diagnostic mammograms on both breasts. And I used to have to follow those procedures with an ultrasound.
 
Therefore I feel breast cancer awareness is an extremely important topic, one I can’t stress enough. Breast cancer is the most common type of cancer among American women and is the second leading cause of death. The disease affects mostly women, but there is an increasing number of documented cases of male breast cancer.  
 
Breast cancer is a malignant neoplasm (i.e., abnormal growth) that starts from cells from the breast. Most breast cancers begin in the ducts (i.e., ductal cancer), the tiny tubes that carry milk from the lobules to the nipple. Other women get lobular cancer, which forms in the cells that line lobules (i.e., the milk-producing glands). A smaller portion of breast cancer patients have tumors that form in other tissues. Breast cancer can metastasize (spread) to the other parts of the body. It is extremely important to identify if the cancer cells have spread to the lymph nodes, as this increases the chance that the cancer cells have reached the bloodstream and through it, other parts of the body. The more lymph nodes that have breast cancer, the more likely the cancer will be found in other organs as well.
 
There is some good news! Most breast lumps are not cancerous. However, patients with these benign neoplasms may need to have them sampled and viewed by a physician to verify they are not cancer. Most lumps turn out be fibrocystic (e.g., fibroids and cysts) changes. Other types of benign tumors such as fibroadenoma or interductal papilloma are abnormal growths, but they are not cancerous. Although these are all considered benign tumors, it is extremely important that women continue routine checks if they have them as they put women at a higher risk for developing breast cancer in the future.
 
Risk factors for breast cancer
Risk factors don’t tell us who will develop breast cancer and who won’t. There are many cases where a woman develops breast cancer but has no risk factors and there are others who have high risk factors and never develop the disease. Of course, monitoring personal behavior (e.g., not smoking or drinking excessively, watching your diet, limiting contact with cancer-causing agents) is recommended.
 
Some risk factors of breast cancer cannot be changed. For instance, gender (women are at a higher risk than men), age (women older than 55 are more likely to develop invasive breast cancer than those under the age of 45) and genetic risk factors (BRCA1 and BRCA2 gene mutation is the most common cause of hereditary breast cancer) all play a role. Family history of breast cancer also increases a person’s chance of developing breast cancer. Having one family member with the disease doubles your chances; having two relatives increases your chances five-fold. Ethnicity is another risk factor—Caucasian women are at a higher risk than other ethnicities. However, African-American women who develop the disease are more likely to die from breast cancer.
 
There are other risk factors such a dense breast tissue, which makes cancer more difficult to detect. Because of this, effective October 1, 2009 there is a new diagnosis code 793.82 to identify an inconclusive mammogram.
 
Finally, certain benign breast conditions can increase your risk for developing breast cancer. Physicians divide these benign conditions into three categories:
  • Nonproliferative (i.e., fibrocystic breast disease)
  • Proliferative (i.e., ductal hyperplasia)
  • Proliferative with atypia (i.e., atypical ductal hyperplasia or atypical lobular hyperplasia)
Proliferative can increase your chances of getting breast cancer by 150–200% whereas proliferative with atypia can increase your chances of developing breast cancer by 400-500%.
 
Detection and diagnosis
Detection or diagnosis of breast cancer generally involves self-breast examinations and screening mammograms. If you or your physician finds something during a screening test or if other signs and symptoms are present, there are several diagnostic options. Imaging tests such as diagnostic mammograms, digital mammograms, computer-aided detection and diagnosis (CAD), magnetic resonance imaging (MRI) of the breast, breast ultrasounds, ductograms, and newer imaging tests such as scintimammography and tomosynthesis are all available. Other diagnostic tests such as nipple discharge exam and ductal lavage and nipple aspiration. Physicians can also use biopsies such as fine-needle aspiration, core needle biopsy, vacuum-assisted biopsies, open surgical biopsy, lymph node dissection and sentinel lymph node biopsy to detect whether a lesion is benign or malignant, the type of cancer, and whether the cancer has spread to the lymph nodes.
 
Some of the common terms used to talk about breast cancer are adenocarcinoma, carcinoma in situ, and invasive/infiltrating carcinoma. Adenocarcinoma is cancer that begins in the glands such as the ducts and lobules of the breast. Carcinoma in situ is a term to describe cancer that is confined to the ducts or the lobules. These cancers have not grown into the deeper tissue of the breast or spread to other organs. Invasive or infiltrating carcinoma is a term to describe cancer that has spread beyond the layer of cells where it began. Most breast cancers are invasive or infiltrating.
 
A pathologist will also assign a grade to the cancer, which is based on how closely the biopsy sample resembles normal breast tissue. The grade is used to determine the woman’s prognosis. This is one time that a lower grade is better! The lower grade indicates a slower-growing cancer that is less likely to spread, while a higher number indicates a faster growing cancer that is more likely to spread. The tumor grade is one of the tools used to determine further treatment after surgery.
 
Treatments for breast cancer
Treating breast cancer is as individual as breast cancer itself. A physician will determine the course of treatment that is best for the type and grade of breast cancer. Surgical removal such as a lumpectomy or partial (segmental) mastectomy, known as breast conserving surgery, is an option for those with stage I or II breast cancer. However, for some women, mastectomy is more likely the course of treatment.
 
Radiation therapy using ionizing radiation is often given after surgical removal. It can be given one of two ways: through external beam radiation, which is the most common, or accelerated breast irradiation. Accelerated breast irradiation involves larger doses of radiation over a shorter period of time. Brachytherapy is another form of radiation a physician might recommend. It involves internal radiation using radioelements (seeds or pellets) placed into the breast tissue. Tumor size, location and other factors determine whether brachytherapy is an option. Chemotherapy is also common choice for treatment of breast cancer. It involves the use of oral or intravenous cancer-killing drugs generally given in cycles. Hormone therapy is another option, and it is often used as an adjuvant therapy to help reduce the risk of recurrence. It can also be used to treat a cancer that has come back or spread after treatment.
 
Breast cancer coding
For a patient admitted for the treatment of a malignant neoplasm of the breast by chemotherapy or radiation therapy, the first listed code is either V58.0, radiotherapy or V58.1x, chemotherapy. Use additional code(s) to identify the malignant neoplasm that is being treated. However, if the patient is admitted for surgical treatment of the malignant neoplasm and receives radiation/chemotherapy, the first listed code should be the malignant neoplasm.
 
Coding for hormone therapy such as Tamoxifen can be tricky as it is used treat breast cancer as well as prevent the recurrence, so it is extremely important for the physician’s documentation specify which scenario is the case. In 2008 a new code (V07.5x) was created to identify the use of prophylactic agents affecting estrogen receptors and receptor levels. (The fifth digit identifies the specific type of drug.) Code V07.5x is only for use as an additional diagnosis.
 
Coders should also use additional codes to identify whether the patient has a personal or family history of breast cancer. There seems to be some conflicting information between the coding guidelines in the ICD-9 Manual and Coding Clinic when Tamoxifen is involved. According to the Manual, coders should first report the applicable malignant neoplasm. However, per Coding Clinic 4th quarter 2008, coders should only report the malignant neoplasm when Tamoxifen is given prophylactically, but not when it is used for active treatment. Therefore, it would not be inappropriate to use this code with malignant neoplasm of the breast. However, keep in mind that a patient being treated with Tamoxifen may have a family history of breast cancer but never had the disease themselves.
 
Herceptin is another drug that is generally prescribed for five years post-surgery to treat HER2 positive breast cancer. This drug is administered intravenously on a weekly basis. According to Coding Clinic 3rd quarter 2009, coders should report code 174.9, malignant neoplasm of the breast, as the first listed diagnosis and V58.69 as an additional diagnosis for the Herceptin maintenance.
 
When it comes to coding for the malignant neoplasm keep in mind the general coding guidelines: First code the neoplasm being treated, which could be either a primary or secondary malignant neoplasm. For complications of malignant neoplasm, chemotherapy or radiation therapy that warrant an admission, code first the complication followed by the malignant neoplasm. When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, code personal history of breast cancer V10.3 to identify the former site of the malignancy.
 
Editor's note: Jennifer Avery, CCS, CPC, CPC-H CPC-I, is a regulatory specialist for HCPro, Inc. You can e-mail her at javery@hcpro.com.

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