It’s good to remember that in fee-for-service medicine CPT coding determines how much you get paid while the ICD-10 diagnosis coding establishes the medical necessity for the claim. When selecting diagnosis codes for suspected, current, and personal history of malignant neoplasms, you need to follow specific rules for ICD-10.
For outpatient claims, do not code for a suspected or possible diagnosis. If a patient presents with coughing up blood, pain, swollen lymph nodes, and a long history of smoking, the physician may suspect lung cancer and can order a test with the diagnosis of “rule out malignant neoplasm.” But the office visit should be coded with the symptoms. There are also codes for abnormal findings without a definitive diagnosis, such as R92.2, “Inconclusive mammogram.”
Malignant neoplasms are coded based on histologic behavior, site, and cell type. Although most family physicians select a code from within their electronic health record, ICD-10 has a neoplasm table by site, with headings for malignant primary, malignant secondary, in situ, benign, uncertain behavior, and unspecified behavior. The ICD-10 rule is to use malignant neoplasm when the patient has evidence of the disease or is still receiving treatment for the cancer.
When a patient’s cancer is successfully treated and there is no evidence of the disease and the patient is no longer receiving treatment, use Z85, “Personal history of malignant neoplasm.” Update the problem list and use this history code for surveillance visits and annual exams.
Follow ICD-10 rules when reporting suspected or confirmed malignancy and personal history of malignant neoplasm. Remember, the codes that are selected stay with the patient.
— Betsy Nicoletti, a Massachusetts-based coding and billing consultant
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