Class 7 Neoplasms, Genitourinary System,& Endocrine, Metabolic

8/9/2019 Class 7 Neoplasms, Genitourinary System,& Endocrine, Metabolic

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Neoplasms, Genitourinary System,& Endocrine, Metabolic, and Nutritional andImmune SystemNeoplasms

Section I.C.2. contains the neoplasm chapter of the Official Coding Guidelines

Chapter 2 of the ICD-9-CM coding book is also the neoplasm chapter

Remember to properly code a neoplasm it is necessary to determine from the documentation

if the neoplasm is benign, in-situ, malignant (primary or secondary), or of uncertainbehavior

Official coding guidelines

Neoplasms

If the histological term is documented (e.g. sarcoma, adenocarcinoma, leiomyoma) that term

should be referenced first, rather than going immediately to the Neoplasm Table

Then by following the instructions given in the alphabetic index either assign a code e.g.

Leiomyoma uterus 218.9 or follow the instructions to go to and where in the NeoplasmTable

Neoplasms

If the documentation does not provide the histological type but does provide the type of

neoplasm (e.g. benign, in-situ) go to the Neoplasm Table and site for the condition

Remember, after choosing the code always reference the tabular index

If the histological type differs from the provider’s stated diagnosis (e.g. malignant adenoma)

code as instructed by the provider’s statementNeoplasms

If the treatment is directed at the malignancy, designate the malignancy as principal diagnosis

The only exception to this guideline is if the encounter is solely for administration of

chemotherapy, immunotherapy or radiation therapy – then assign the appropriate V58.Xcode as the first listed and the neoplasm as secondary

Neoplasms

When the patient is admitted for and the treatment is directed only toward the metastatic

(secondary) site, the secondary neoplasm is designated as the principal even though theprimary site still does or doesn’t exist

Neoplasms

Coding and sequencing of complications associated with the malignancies or their treatment

are subject to the following:

1) Anemia – when the encounter is for management of an anemia associated with the

neoplasm and the treatment is only for the anemia, the appropriate anemia code isdesignated as principal – followed by the malignancy code(s)

Neoplasms

2) when admission is for management of anemia associated with chemo/immuno/radiotherapy

and the only treatment is for the anemia – the appropriate anemia is first listed diagnosis



followed by an E code for the treatmentNeoplasms

3) when the encounter is for management of dehydration due to the neoplasm or therapy or

combination of both and only the dehydration is being treated – the dehydration issequenced first followed by the malignancy code(s)

Neoplasms

4) when the admission is for treatment of a complication resulting from a prior surgical

procedure, assign the postoperative complication code as the principal if treatment isdirected at resolving the complication

Neoplasms

When a primary malignancy has been previously excised/eradicated from its site and there is

no further treatment directed to that site and no evidence of existence of that neoplasm atthat site code a V10 personal history of malignant neoplasm code

Any mention of metastasis to another site is coded as a secondary neoplasm and may be the

principal code with the V10 code as secondary

Neoplasms

Admissions/encounter involving chemotherapy, immunotherapy and radiation therapy:

1) when the encounter involves removal of the neoplasm followed by adjunct chemotherapy or

radiation therapy during the same episode of care – the neoplasm should be principal fromthe 140-198 or 200-203 series

Neoplasms

2) if the encounter is solely for chemotherapy, immunotherapy or radiation therapy assign the

appropriate V58.XX code

If the patient receives more than one of these therapies during the same admission more than

one of these codes may be assigned, in any sequence with the site of the neoplasm assecondaryNeoplasms

3) when admitted for radiation therapy, immunotherapy or chemotherapy and the patient

develops a complication (e.g. nausea/vomiting/dehydration) the first listed diagnosis is theappropriate V58.XX code followed by the complicating conditions

Neoplasms

When the reason for admission is to determine the extent of the malignancy or for a procedure

such as a paracentesis or thoracentesis – the primary malignancy or metastatic site isdesignated as principal even though chemotherapy or radiotherapy is administered

Neoplasms

Symptoms, signs and ill-defined conditions from chapter 16 characteristic of, or associated

with, an existing neoplasm cannot be used to replace the malignancy as principalregardless of the number of admissions or encounters for treatment and care received

Neoplasms

For encounters for prophylactic removal of breasts, ovaries, or another organ due to a genetic

susceptibility to cancer or a family history of cancer, the principal code should be a codefrom subcategory V50.4X followed by the appropriate genetic susceptibly code and familyhistory



Neoplasms

If the patient has a malignancy of one site and is having prophylactic removal at another to

prevent spread - a code for the malignancy should be assigned in addition to a code fromsubcategory V50.4X

A V50.4X should not be assigned if the patient is having organ removal for treatment of amalignancy – such as removal of the testes for treatment of prostate cancer


Neoplasms

When the admission or encounter is for pain control/management – refer to section I.C.6.a.5

Disease of the Nervous System and Sense Organs


Neoplasms

A malignant neoplasm of a transplanted organ should be coded as a transplant complication

Assign first the appropriate code from subcategory 996.8X followed by code 199.2 –

malignant neoplasm associated with transplanted organ – use an additional code for thesite of the malignancy


Genitourinary System

Renal failure (subcategories 584.X, 585.X is a progression of renal insufficiency where renal

function is further impaired and overt clinical consequences (e.g. anemia) develop

Renal insufficiency is more an abnormal laboratory finding while failure incorporates both lab

and clinical findings

CC 1/93 p 18


If irreversible CKD the treatment of choice may be dialysis or transplantation

Acute renal failure may be temporary

Documentation might indicated renal failure when markedly abnormal elevated values of

serum creatinine or BUN or diminshed creatinine clearance

CC 1/93 p 18


Chronic kidney disease:

1) the ICD-9-CM classifies CKD based on severity stages 1-5 (I-V) codes 585.1-585.5

Code 585.6 is for ESRD (end-stage renal disease)



If both a stage and ESRD is documented, code 585.6 for end-stage, only



2) patients who have undergone kidney transplant may still have some form of CKD

The presence of CKD only does not constitute a transplant complication

Assign the 585.X for the CKD and V42.0



If a transplant complication such as failure or rejection or other transplant complication is

documented code 996.81 should be assigned

Code 996.81 should not be assigned for post kidney transplants who only have CKD

If the documentation is unclear, query the provider



For patients with CKD who also suffer from other serious conditions (e.g. diabetes,

hypertension) sequencing of the CKD code in relationship to codes for other contributingconditions is based on conventions in the tabular index

9/10/84 p 1


An exclude note is present with category 403.XX to indicated that acute renal failure (584.X)

and renal disease stated as not due to hypertension are excluded from this category unlessstated otherwise

At category 403 include note reads “any condition classifiable to 585,586,587 with any

condition classifiable to 401” so the mention of both conditions constitute hypertensiverenal disease (403)

CC 4/92 p 22-23


The association is not true for acute renal failure which may be independent of hypertensive

disease

The note, “Excludes: hypertensive renal disease (403.0-403.9),” at the beginning of the renal

the renal disease section 580-589 applies to all conditions in this section which maybecome part of hypertensive renal disease – it does not mean automatic combination withall these condtions

CC 4/92 p 22-23




Question: patient admitted for evaluation of chronic dysarthria – after work-up the physician

diagnosed acute kidney injury secondary to volume depletion – this patient has no historyof trauma – how should this be coded

CC 4/08 p 192 - 193


Answer: assign 584.9 (effective 10/1/08 changes were made to the alphabetic index to

include the term of nontraumatic acute kidney injury

CC 4/08 p 192-193


Question: is it appropriate to assign code 599.0 UTI with code 595.0 acute cystitis when the

physician documents both?

Answer: assign only 595.0 if the physicain states the bladder is the specific site of the acute

infection – code 599.0 should be assigned if the physician has not, or is not able to identifythe site - if the terms “acute cystitis” and UTI are documented code only the cystitis

CC 2/99 p15-16


What is the correct coding and sequencing of benign prostatic hypertrophy with bladder neck

obstruction when a TURP and release of the obstruction is performed

CC 3/94 p 12


Answer: Assign the code for hyperplasia of the prostate (600.91) as the principal – the

bladder neck obstruction (596.0) would be listed as secondary – since the bladder neckcontracture is frequently part of the condition resulting in BPH – a procedure is performedfor both and sequence the main condition first – unless the bladder neck contracture is dueto something else

CC 3/94 p 12


Question: what is the code for gross hematuria due to trauma resulting from a senile patientpulling out the urinary retention catheter?

Answer 867.0 injury to urethra without mention of open wound - E928.9 – self inflicted injury

stated as accidental - 599.70 hematuria

CC 11/12/85 p 15




612.0 contour deformity can develop in reconstructed breast – treatment can include fat

injections to improve the contour (note – this is not a complication code)

612.1 breast asymmetry refers to a difference between the breasts in shape or size

CC 4/08 p 123Genitourinary System

Question: what is the sequencing of codes for a screening mammograms for patients with

know fibrocystic disease?

Answer: assign V76.12 as the first listed code and 610.1 additionally – fibrocystic breast

disease is a normal variant – not a pathological condition

CC 2/06 p 10


Question: A patient with a breast mass is referred to radiology for a diagnostic mammogram –

Code?

Answer: Code any positive findings found on the diagnostic mammogram as the first listed

diagnosis or 611.72 for breast mass – do not assign V76.12 screening – screenings are for patients without problems – diagnostic mammograms should have diagnosis, sign or symptoms

CC 2/03 p 4-5

Endocrine, Metabolic, Nutritional & Immune Systems

Diabetes mellitus is a disorder of glucose metabolism due to either absolute decrease in

insulin or reduction in biologic effectiveness of the insulin secreted

There are two major categories Type I and Type II they are broken into four subcategories at

the fifth digit level for Type I, Type I uncontrolled, Type II and Type II uncontrolledEndocrine, Metabolic, Nutritional & Immune Systems

Other conditions confused with true diabetes include – impaired glucose tolerance, a mild

impairment of glucose metabolism indentified by a abnormal glucose tolerance test andgestational diabetes – abnormal glucose tolerance during pregnancy

CC 3/91 p 3-12


There are a variety of other conditions such as pancreatitis, carcinoma of the pancreas,

hemochromatosis, pheochromocytoma, and drug usage (e.g. steroids) which can cause

secondary diabetes

CC 3/91 p 3-12


Diabetes can lead to a wide variety of complications – metabolism, kidneys, eyes, peripheral

nerves, peripheral blood vessels



These complications are indicated by the fourth digit code

CC 3/91 p 3 - 12


Type I – fifth digit of 1 onset usually occurs prior to age 40 and most commonly in juveniles

Insulin therapy is required – however there may be brief symptom free intervals

Type I patients have a tendency to develop ketoacidosis (DKA)


Type II – fifth digit of 0 – onset occurs in adults, beginning in midlife or beyond – however,

Type II may have its onset in juveniles

Generally do not require insulin therapy, however, may be required to correct symptomatic

hyperglycemia – usually managed with weight reduction

CC 3/91 p 3 - 12


Glucose impairment 790.21 and 790.22

This includes patients who do not have diabetes

They are identified by the performance of a glucose tolerance test

CC 3/91 p 3 - 12


648.0X – diabetes complicating pregnancy – women with pre-existing diabetes, whose

diabetes complicates the pregnant state, is aggravated by the pregnancy, or is the mainreason for care

Pregnant woman with pre-existing diabetes is assigned code 648.0X with a secondary code

for the type

CC 3/91 p 3-12


648.8X abnormal glucose tolerance complicating pregnancy that appears during pregnancy in

a previously non-diabetic patient

They are placed on diabetic diets and may require insulin. They are at increased risk to

develop Type II diabetes later

CC 3/91 p 3 - 12


775.0 Syndrome of Infant of a Diabetic Mother – when a newborn infant of a diabetic or

gestational diabetic mother manifest features of this condition (large, decrease in blood



sugar) this code is the correct code for assignment

CC 3/91 p 3 - 12


775.1 – Neonatal Diabetes Mellitus – this refers to a transient diabetic state occurring in thenewborn infant of a diabetic mother – may also be referred to as “pseudodiabetes”

CC 3/91 p 3 - 12


Secondary diabetes mellitus – the information in Coding Clinic 3/91 p 6 is obsolete instead

refer to the Official Coding Guidelines Section I.C.3.a.7 and Coding Clinic 4/08 page 91-95

Codes under category 249 secondary diabetes mellitus, identify complications/manifestations

associated with secondary diabetes

Official Coding Guidelines


Secondary diabetes is always caused by another condition

(a) fifth digits codes required to identify whether documented as controlled or uncontrolled

(b) for patients who take insulin collect V58.67 also – but should not be assigned if the insulin

in given temporarily



(c) when assigning codes for secondary diabetes and associated conditions (e.g. renal) the

codes from 249 must be sequenced before the associated condition – assign as manycodes from category 249 as needed to identify all conditions



(d) the sequencing of secondary diabetes codes in relationship to codes for the cause of the

diabetes is based on the reason for the encounter, applicable to coding conventions andchapter guidelines

If the patient is seen for treatment of the secondary diabetes or one of its associated

conditions 249.X is sequenced first, with cause as an additional code



If the patient is seen for treatment of the condition causing the secondary diabetes (e.g.

pancreatic cancer) the code for the cause of the secondary diabetes should be sequencedas the principal followed by the 249





(i) secondary diabetes mellitus due to pancreatectomy – assign 251.3 Post-surgical

hypoinsulineima - assign a code from subcategory 249 and code V45.79, - code also any

diabetic manifestation (diabetic nephrosis 581.81)



(ii) Secondary diabetes due to drugs - this diabetes may be caused by adverse effects of

correctly administered medication, poisoning or late effect of poisonings and should followthose guidelines



There are two types of complications that may occur with diabetes – one of these is the acute

metabolic complication that is part of the diabetes itself and does not require and additionalcode – the other is the chronic effect that occurs in another body system (codes 250.4CX –250.8X) with additional code for the manifestation

CC 3/91 p 6


Diabetes ketoacitosis is assigned 250.13 (see CC 2/06 p 20)

Typical findings are glycosuria 4+, strong ketonuria, hyperglycemia, ketonemai, acidosis, and

low plasma bicarbonate

CC 3/91 p 6-7


250.2X diabetes with hyperosmolar coma – involves an altered state of consciousness without

significant ketosis, but with hyperosmolarity and dehydration

Code assignment includes the altered mental status and other neurological deficits

CC 3/91 p 7


250.3X diabetic with other coma includes diabetic ketoacidosis with progression to a

comatose state and hyperglycemic coma

CC 3/91 p 7




250.9X – diabetes with unspecified complication – this category includes metabolic

complications which cannot be assigned elsewhere (e.g. hyperosmolarity withoutneurological deficit

CC 3/91 p 7


250.4X Renal manifestation – such as diabetic neuropathy with the renal manifestation code

of 583.81

Diabetic nephrosis and nephrotic syndrome 250.4X & 581.81

Both refer to lesions occurring in the kidney of the diabetic patient

CC 3/91 p 8


250.5X – diabetic eye disease such as retinopathy, macular edema, background and

proliferative retinopathy

Diabetic cataracts “snow flake cataract” 250.5X and 366.41 – senile cataract 250.5X and

366.10

CC 3/91 p 9


250.6X diabetic neuropathy – which is peripheral, cranial, and or autonomic neuropathy 357.2

Polyneuropathy 250.6X & 337.1


250.7X diabetic peripheral circulatory disorders – arteriosclerosis occurs earlier and more

extensively in diabetes

Diabetic peripheral vascular disease causing intermittent claudication 250.7X and 443.81

Diabetic atherosclerosis with gangrene 250.7X – 440.2X and 785.4

CC 3/91 p 10


250.8X other

Diabetic osteomyelitis 250.8X 730.8X and 731.8

If the cause of a diabetic ulcer or diabetic impotence is not known code 250.8X applies

CC 3/91 - 10




Diabetic foot ulcers may be cause by diabetic neuropathy 250.6X peripheral vascular disease

250.7X or an infection

With an infection, a diabetic complication is not coded.

Sequencing depends on the circumstances of admission

If cause is unavailable, query provider, if unknown, 250.8X is applied

CC 3/91 p 10-11


Organic Impotence in diabetes – if due to peripheral vascular disease code 250.7X if due to

neuropathy 250.6X if unknown or undetermined 250.8X

CC 3/91 p 11


Cystic fibrosis guidelines

It is a disorder of the exocrine gland that causes accumulation of very thick mucus and

abnormal concentrations of sodium and chloride in sweat and saliva

Complications that occur are primarily due to the thick mucus

CC 4/90 p 16


Cystic fibrosis is primarily caused by pancreatic deficiency and chronic malabsorption inchildren

There is no know cure – therapy is targeted at the complications – organ tranplant is also an

option

CC 4/90 p 15


Body systems affected:

Pancreas – thick mucus prevents pancreatic enzymes from reaching the duodenum

Pulmonary – thick mucus causes bronchial and bronciolar obstruction

Cardiac – right ventricular hypertrophy occur as a result of the pulmonary issues

CC 4/90 – 16-17


Biliary – obstruction and fibrosis occur resulting in cirrhosis



Reproductive – males are likely to be sterile

CC 4/90 p 16-17


Codes 277.00 – 277.09

Pulmonary involvement 277.02 – often CF patients get pseudomonas infections in the lungs –

then the secondary code is the organism 041.7 – this is not equivalent to pneumoniaThe patient my present with multiple co-existing conditions – all should be codedCC 4/02 p 45-46Endocrine, Metabolic, Nutritional & Immune Systems

The treatment depends on the stage of the disease and organ involved

277.03 is gastrointestinal involvement – can result in the body not being able to absorb

nutrients, maintained on an enriched diet with vitamin and enzyme replacement.

CC 4/02 p 45-46


In accordance with UHDDS requirements, the condition that occasions the admission should

be principal diagnosis

If the patient is admitted due to a complication such as pneumothorax, acute bronchitis, acute

cor pulmonale, the complication or manifestation should be sequenced first and the cysticfibrosis reported additionally

CC 4/02 p 45-46


If the provider determines that the admission/encounter is due to the cystic fibrosis rather than

the complication, sequence the cystic fibrosis first

CC 4/02 p 45-46


Question: the patient has a history of cystic fibrosis and bilateral lung transplant – is now

admitted because of his cyclosporine levels sub-therapeutic leading to rejection – this isunknown as to whether this was due to lack of compliance or increased metabolism of oralcyclosporine

CC 2/03 p 12


Answer: assign 996.84 complication of lung transplant - the main problem was the chronic

rejection – assign 277.00 as a secondary code



CC 2/03 p 12

Class 7 Neoplasms, Genitourinary System,& Endocrine, Metabolic

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