A&P Focus: Neoplasms Lesson 4: ICD-10-CM Neoplasm Coding

How to Code a Neoplasm in ICD-10-CM

1. First, reference the Main Term in the ICD-10-CM Index to Diseases and Injury for the histological type of neoplasm if it is documented.

In this Endometrioid Carcinoma example, the histological type is documented and can be found as a main term in the ICD-10-CM Index to Diseases and Injury.

Example for Step 1: Endometrioid Carcinoma in a Female

Carcinoma

2. Next, search the subterm entries to see if site-specific (or more specific) information can be referenced.

a. In the Endometrioid Carcinoma example, a specific code, C56.9, Carcinoma, endometrioid, female, is listed in the ICD-10-CM Index to Diseases and Injury.

Example for Step 2: Endometrioid Carcinoma in a Female, Step 2

Carcinoma -endometrioid --unspecified site ---female C56.9

Because the code has been identified, proceed to Step 4.

b. When the site is not listed as a subterm or when a specific code is not given in the index, follow any instructional notes provided. In this Brain Cancer example, an instructional note must be followed.

Example for Step 2: Brain Cancer, Primary Site

Cancer – see also Neoplasm, by site, malignant

The coder is told to "see also Neoplasm, by site, malignant". This means that the coder needs to review the Neoplasm Table in order to code Brain Cancer, Primary Site.

Because the code has NOT been identified, proceed to Step 3.

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A&P Focus: Neoplasms Lesson 4: ICD-10-CM Neoplasm Coding

How to Code a Neoplasm in ICD-10-CM

3. Because a code has not as yet been identified for Brain Cancer, Primary Site, reference the ICD-10-CM Table of Neoplasms to locate the anatomical site.

In Step 2, the instructions were to "see also Neoplasm, by site, malignant". In this Brain Cancer example, the anatomical site "Brain NEC" is one of the entries found in the Table of Neoplasms under "Neoplasm, neoplastic".

Example for Step 3, Part 1: Coding Brain Cancer, Primary Site Malignant Malignant Ca in Uncertain Unspecified Benign Primary Secondary Situ Behavior Behavior Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9 … … … … … … … Brain NEC C71.9 C79.31 - D33.2 D43.2 D49.6

Now that the appropriate entry is located, the next step is to move across its row to the appropriate behavior type column and select the code. In this Brain Cancer example, the appropriate behavior type is "Malignant Primary".

Example for Step 3, Part 2: Coding Brain Cancer, Primary Site Malignant Malignant Ca in Situ Benign Uncertain Unspecified Primary Secondary Behavior Behavior Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9 … … … … … … … Brain NEC C71.9 C79.31 - D33.2 D43.2 D49.6

4. The final step is to look up the code in ICD-10-CM Tabular List and review all includes and excludes notes.

a. In this Endometrioid Carcinoma example, there is note under C56 that applies to C56.9. The note instructs "Use additional code to identify any functional activity."

Example for Step 4: Endometrioid Carcinoma in a Female

C56 Malignant neoplasm of ovary Use additional code to identify any functional activity C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary

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A&P Focus: Neoplasms Lesson 4: ICD-10-CM Neoplasm Coding

How to Code a Neoplasm in ICD-10-CM

(4. continues)

b. In this Brain Cancer example, there is an Excludes1 note for category C71. The Excludes1 note under category C71 applies to all of the codes under category C71, including C71.0.

Example for Step 4: Brain Cancer, Primary Site

C71 Malignant neoplasm of brain Excludes1: malignant neoplasm of cranial nerves (C72.2-C72.5) retrobulbar malignant neoplasm (C69.6-) C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles Malignant neoplasm of supratentorial NOS C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of occipital lobe C71.5 Malignant neoplasm of cerebral ventricle Excludes1: malignant neoplasm of fourth cerebral ventricle (C71.7) C71.6 Malignant neoplasm of cerebellum C71.7 Malignant neoplasm of brain stem Malignant neoplasm of fourth cerebral ventricle Infratentorial malignant neoplasm NOS C71.8 Malignant neoplasm of overlapping sites of brain C71.9 Malignant neoplasm of brain, unspecified

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