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Oncology

Ch 2: Neoplasms

ICD-9-CM

Anatomical site
Histologic behavior:

  • Malignant Primary
  • Malignant Secondary
  • In situ
  • Benign
  • Uncertain
  • Unspecified behavior

Skin neoplasms:

  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Specified type NEC

 

Ch 2: Neoplasms

ICD-10-CM Requirements

General Documentation:

  • Anatomical Site
  •  Laterality (left, right)
  • Histologic behavior:
    – Benign
    – Malignant, primary and secondary sites if metastatic
    – In situ
    – Uncertain
    – Unspecified behavior
  • Histologic Type:
    – Carcinoma
    – Basal Cell
    – Squamous Cell
    – Adenoma
  • Complications or Adverse effects of antineoplastic or immunosuppressive drugs
  • Previous excision or eradication

Breast, in-situ, document:

  • Lobular
  • Intraductal

Leukemia, Multiple Myeloma, Malignant plasma cell neoplasms, document:

  • Relapse
  • Remission
  • Not having achieved remission

Ch 2: Neoplasms

Notes

Pathologists may need to work with their referring physician to obtain this information.
When patients have more than one malignant tumor in the same organ document the primary and metastatic disease.

Ch 3: Blood Disorders

ICD-9-CM

Most Intra-operative & Post- procedural complications are included in Chapter 17 – Injury and Poisoning.

Ch 3: Blood Disorders

ICD-10-CM Requirements

Anemia, document:

  • Nutritional, specify:
    – Iron deficiency
    – Vitamin B12 deficiency
    – Folate deficiency (dietary or drug-induced)
    – Other (protein, megaloblastic)
  • Hemolytic, specify:
    – Due to enzyme disorders
    – Sickle-cell disorders
    – Other hereditary or acquired
  • Aplastic
  • In other chronic diseases (specify the underlying disease)

Spleen document Intra-operative & Post-procedural complications, specify:

  • Intra-operative (during) or Post-procedural (following)
  • Hemorrhage, hematoma, accidental puncture or accidental laceration of the spleen
  • Procedure on the spleen or other procedure

Ch 3: Blood Disorders

Notes

Intra-operative & Post-procedural complications are also included in other chapters based on specific site/system documentation.

Ch 12: Skin

ICD-9-CM

Anatomical site
Specimen type i.e., cyst, tag, abscess, ulcer, scar, etc.
Neoplasm skin and subcutaneous tissues see Chapter 2 guidelines.
Dermatitis, document if:

  • Atopic
  • Seborrheic
  • Diaper
  • Exfoliative
  • Contact (due to…)
    – Irritant contact (due to…) & Unspecified contact (due to…)

Pressure Ulcer

Ch 12: Skin

ICD-10-CM Requirements

General Documentation:

  • Anatomical site
  • Laterality

Pressure ulcer, document:

  • Site
  • Laterality
  • Specify stage:
    – Unstageable (can’t be clinically determined)
    – Stage 1
    – Stage 2
    – Stage 3
    – Stage 4

Dermatitis, document:

  • Atopic
  • Seborrheic
  • Diaper
  • Exfoliative
  • Contact
    – Allergic (specify: due to…)
    – Irritant (specify: due to….)

Non-pressure ulcer, document:

  • Site
  • Laterality (left or right)
  • Severity:

– Limited to breakdown of skin
–  With fat layer exposed
–  With necrosis of muscle
–  With necrosis of bone

Ch 12: Skin

Notes

Neoplasm skin and subcutaneous tissue are included in Chapter 2.
Pressure ulcer staging is generally identified by the clinician.
As with ICD-9-CM, Pathologists may need to work with their referring physician to obtain this information.
Non-pressure ulcers are included in Chapter 19.

Ch 18: Signs/Symptoms Clinical Lab Findings

ICD-9-CM

This section includes symptoms, signs, abnormal results of laboratory or other investigative procedures and ill- defined conditions regarding which no diagnosis classifiable elsewhere is recorded.

Ch 18: Signs/Symptoms Clinical Lab Findings

ICD-10-CM Requirements

General Documentation:

  •  Repeated falls
  •  Coma scale,
    – Glasgow coma scale, total score, must be documented in the medical record, not the individual score, in order to assign diagnosis codes.
  •  Functional quadriplegia must be specifically documented in the medical record in order to assign R53.2.
  • SIRS due to non-infectious process
    – Documentation must clearly indicate that SIRS was due to a non- infectious process (i.e., trauma, malignant neoplasm or pancreatitis).

Ch 18: Signs/Symptoms Clinical Lab Findings

Notes

Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditional regarding which no diagnosis classifiable elsewhere is recorded. Signs and symptoms that point to a specific diagnosis have been assigned to a category in other chapters of the classification.

Ch 21: Factors Influencing Health

ICD-9-CM

ICD-9 V-codes:

  •  Screening
  •  History of
  •  Contact/Exposure
  •  Follow-up
  •  Pre-Operative

Ch 21: Factors Influencing Health

ICD-10-CM Requirements

General Documentation:

  •  Specific purpose for receiving services
  •  Circumstance that affects the patient’s health status but is not a current illness or injury. Key Terms include:
    – Examination, History, Fitting, Status, Screening, etc…
  •  Contact/Exposure: document if with or suspected to communicable disease.
  •  Inoculations and vaccinations document if:
    – Prophylactic inoculation against disease, or
    – Screening for patient without sign or symptom (e.g. encounter of screening mammogram for malignant neoplasm of breast)
  • Documenting “History of” indicates the condition no longer exists but is being monitored) (e.g. personal history of malignant neoplasm of breast)
  •  Documenting “Follow-up” indicates continued surveillance following completed treatment (e.g. Encounter for routine postpartum follow-up)
  •  Pre-operative for patients receiving preoperative evaluation only (e.g. Encounter for pre-procedural exam [Specify – Cardio/ Resp./lab /other])
  •  Aftercare; Follow-up; Donor; Counseling and Obstetrical services.
    – Specify as applicable.

Ch 21: Factors Influencing Health

Notes

ICD-9-CM V-codes are now Z- codes, which may be used as primary or secondary.
May be used in any healthcare setting.

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