HS317b - Advanced Health Informatics

Neoplasms Chapter II

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Cancer - see also Neoplasm, malignant(8000/3)

Malignant

Carcinoma In Situ

  • Refers to neoplastic cells in a preinvasive stage of cancer
  • Other terms: intraepithelial, noninfiltrating, non-invasive, preinvasive

Morphology Classification

  • Describes the cell of origin (histological type)
  • Describes the behaviour of neoplasm
  • Optional to use
  • Consists of five digits:
  • First four identify histological type of neoplasm
  • /Fifth indicates behaviour
  • /0 Benign
  • /1 Uncertain whether benign or malignant
  • /2 Carcinoma in situ
  • /3 Malignant, primary site
  • /6 Malignant, metastatic site
  • /9 Malignant, uncertain whether primary or metastatic

The ICD-O behaviour digit /9 is not applicable in the ICD context, since all malignant neoplasms are presumed to be primary (/3) or secondary (/6), according to other information in the medical record.

A coding difficulty sometimes arises where a morphological diagnosis contains two qualifying adjectives that have different code numbers. An example is "transitional cell epidermoid carcinoma". "Transitional cell carcinoma NOS" is 8120/3 and "epidermoid carcinoma NOS" is 8070/3. In such circumstances, the higher number (8120/3 in this example) should be used, as it is usually more specific

Neoplasm

  • Note MRDx definition – code based on what they are treating. A secondary site can be MRDx if it is accountable for the patient’s LOS
  • Specificity Standard
  • Assign a separate code for each primary and secondary
  • Includes Lymphatic & haematopoietic tissues if documented in more than one site
  • C80 Malignant neoplasm without specification if documentation vague in identifying a primary but a secondary was clearly diagnosed.
  • Morphology optional

Primary Neoplasm:

  • Invasion extending into adjacent tissue, still connected to original site
  • Code to point of origin
  • Overlapping Boundaries (Contiguous Sites)
  • Within a 3-digit category, point of origin undetermined
  • Classify to subcategory .8
  • Separate 3-digit category, point of origin undetermined
  • Code Ca of overlapping site
  • See notes at the beginning of Chapter II for overlapping code
  • If documentation not clear whether malignancy is primary or secondary Q 4024
  • Always presume to be primary
  • Exceptions: bone, brain, diaphragm, heart, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum and spinal cord
  • These are presumed to be secondaries

Follow up admissions

  • Recurrent Malignancies
  • Previously eradicated but recurred in same organ or tissue
  • Code as primary + personal history of malignancy
  • Admission for definitive intervention after diagnosis of cancer made
  • MRDx: primary neoplasm
  • Also when pathology is negative for malignancy and the intent is to remove cancer
  • Observation for suspected malignant neoplasm
  • Z03.1 Observation for suspected malignant neoplasm
  • Malignancy ruled out
  • No further treatment is necessary

History of Malignant Neoplasms

  • Personal history of malignant neoplasm Z85.~
  • Never to be used as MRDx
  • Assign diagnosis type 3
  • Not assigned for secondary malignancy
  • Assign only for primary neoplasm when:
  • The malignancy has been completely eradicated or excised
  • No further treatment is being directed to primary site
  • There is no evidence of any remaining malignancy at primary site
  • There is a recurrence at the same site that was previously excised
  • Follow up examination after treatment for malignant neoplasm Z08.~ when no disease is found
  • Family History of Malignancy Neoplasm
  • Never used as MRDx
  • Denotes reason for prophylactic organ removal

Prophylactic Organ Removal Z40.~ ~

  • No disease is present
  • Family history of malignancy
  • Tests PSA (Prostate Specific Antigen) or CA 125 (Cancer Antigen) positive

Complications of Malignant Disease

If complications are the cause for admission

  • Code as most responsible diagnosis
  • Code malignancy as diagnosis type 3
  • Common complications:
  • Bacterial sepsis A40.~ or A41.~
  • Chemotherapy induced neutropenia D70.0 with Y43.~
  • Febrile neutropenia D70.0 (Q 7676) + Fever, unspecified R50.9
  • Dehydration
  • Hypercalcemia

Neutropenia: an abnormally low level of neutrophils in the blood. Neutrophils are white blood cells producedinthe bone marrow that ingest bacteria. It is sometimes called agranulocytosis or granulocytopenia. It is a serious disorder because it makes the body vulnerable to bacterial & fungal infections.

Dagger/Asterisk

  • Anaemia
  • in neoplastic disease NEC (see also Neoplasm) (8000/1) D48.9 D63.0
  • Pathological fracture
  • Bone - – – in (due to) neoplastic disease NEC (see also Neoplasm)D48.9 M90.7

Summary:

  • Has the malignancy been either excised or eradicated (surgically or non-surgically)?
  • Is no further treatment being directed to the primary site?
  • Is there no further evidence of remaining malignancy at the primary site

Interventions

  • MRDx is Z51.1 Chemotherapy session for neoplasm
  • Neoplasm (active & historical malignancies) may be coded as diagnosis type 3
  • Intervention: 1.ZZ.35.~ ~ (identify specific drug) for systemic or total chemotherapy
  • Radiation therapy Z51.0
  • Neoplasm (active & historical malignancies) may be coded as diagnosis type 3
  • Intervention 1.~~.27.~~~~ Radiation therapy includes anatomical site + type of radiation
  • Brachytherapy 1.QT.26.~~.~~ (implant of radioactive material)
  • MRDx is Malignancy

Interventions

  • Therapeutic – destruction, excision partial, excision total, excision radical, Excision with reconstruction
  • Diagnostic – inspection, biopsy

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