Diagnosis coding for possible malignancy
How would you feel if your primary care physician and your general surgeon told you—and told your insurance company on a claim form—that you had breast cancer, when you didn’t have breast cancer?
You actually had atypical ductal hyperplasia, not breast cancer. Not only have they told you, the claim has gone to your insurance company and the insurance company thinks you have breast cancer. And, it is listed in your electronic medical record on your problem list.
Anyone who works in healthcare knows that removing a diagnosis from a medical record at the physician office, at the hospital, and in the insurance company’s records will be difficult.
Think about the repercussions for this patient if she later needs to buy life insurance, disability insurance, or a health insurance in a state that allows charing higher rates based on pre-existing conditions.
How did this happen?
Neither the primary care physician nor the surgeon followed ICD-10 coding rules and coded the abnormal sign/symptom.
Instead, they coded the suspected diagnosis.
The patient had a screening mammography done. The mammogram showed clustered calcifications in one of her breasts “and a low suspicion for malignancy.” Soon thereafter, she had a biopsy. The result of that biopsy was atypical ductile hyperplasia “bordering on ductal carcinoma in situ.”
Her family physician saw her and assigned the diagnosis of D05.12, carcinoma in situ. She went and saw the surgeon who stated in the narrative that she had “possible low-grade ductal carcinoma” and scheduled a lumpectomy.
The surgeon also assigned D05.12, carcinoma in situ. Two claims have so far been submitted to this patient’s insurance company stating that she has carcinoma in situ.
The final pathology report said there was no evidence of carcinoma in situ.
At the post op visit, the surgeon assigned code N60.92, atypical ductal hyperplasia. This was in the global period, so no claim was submitted to the payer for the visit. And, the patient’s problem list at this visit still lists “ductal carcinoma in situ of the breast.”
When a diagnosis is suspected, it is incorrect to use that diagnosis code on the claim form.
Use a sign or symptom. There are diagnoses for either inconclusive findings on mammogram or calcification or microcalcification on mammogram.
Don’t rush to assign DCIS if the biopsy results says “bordering on…” In this case, the practice needs to remove the diagnoses from the problem list and correct the claim with the insurance company.
|Mammographic microcalcification found on diagnostic imaging of the breast
|Mammographic calcification found on diagnostic imaging of the breast
|Other abnormal and inconclusive findings on diagnostic imaging of the breast
If a neoplasm is unconfirmed, code the sign or symptom. (See below under uncertain diagnosis). And, keep in mind the ICD-10 coding rules for reporting confirmed neoplasms.
Use a malignant neoplasm code if the patient has evidence of the disease, primary or secondary, or if the patient is still receiving treatment for the disease.
If neither of those is true, then report personal history of malignant neoplasm.
Do not continue to report, that is, do not continue to assign in the assessment and plan and send on the claim form—that the patient has cancer.
Here are the instructions from the ICD-10 book
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.
Primary malignancy previously excised
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, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
Follow ICD-10 coding rules when reporting suspected or confirmed malignancy and personal history of malignant neoplasm. Remember, the codes that are selected stay with the patient.