Understanding the

ICD-10-CM
Neoplasm Coding
Guidelines

Sarah A. Serling, CCS, CPC, CCS-P, CPC-H, CEMC, CPC-I, Approved ICD-10-CM/PCS Trainer
October 14, 2015
 Objectives
In this session we will:

Examine the classification of

neoplastic disease in ICD-10-CM
Chapter 2: Neoplasms (C00-D49)

Identify the documentation needed

to properly code a neoplasm

Review how to locate codes for

neoplasms using the Neoplasm
Table

Study the general and chapter-

specific guidelines, coding
conventions, and sequencing rules
for assigning ICD-10-CM neoplasm
codes
 | 3

Introduction
Cancer is the second most common
cause of death in the United States,
according to the Centers for Disease
Control and Prevention (CDC).

The most common cancers include

lung cancer, breast cancer, and
colorectal cancer.

Accurate coding of neoplastic disease

requires a solid understanding of the
ICD-10-CM coding guidelines.

This one-hour session will review the

guidelines, conventions and sequencing
instructions for coding neoplasms in
ICD-10-CM.
 | 4

Understanding ICD-10-CM Neoplasm Coding Guidelines

ICD-10-CM Coding Guidelines

 | 5

What are the ICD-10-CM Guidelines?

The ICD-10-CM Official Guidelines for Coding and Reporting are rules that
supplement the conventions and instructions within the ICD-10-CM classification.
Adherence to these guidelines is required under the Health Insurance Portability
and Accountability Act (HIPAA).

Source: http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2016
 | 6

Where can I find the ICD-10-CM Guidelines?

The CDCs National Center for Health Statistics (NCHS) and the Centers for Medicare
and Medicaid Services (CMS) provide the guidelines for coding with ICD-10-CM.

http://www.cdc.gov/nchs/icd/icd10cm.htm
 | 7

Where can I find the ICD-10-CM Guidelines?

Here is the Centers for Medicare and Medicaid Services (CMS) webpage with the
ICD-10-CM coding guidelines: https://www.cms.gov/Medicare/Coding/ICD10/index.html
 | 8

Understanding ICD-10-CM Neoplasm Coding Guidelines

What is Neoplastic Disease?

 | 9

What is Neoplastic Disease?

Cancer describes diseases with abnormal

cellular growth (neoplasia) that often invades
surrounding tissues or spreads to other sites.

Neoplasm: new growth"

(Neo = new) + (Plasm = growth, formation)

Coding and Documentation Note:

Cancer and malignant neoplasm

are often used interchangeably but

Neoplasm is not synonymous with

cancer. Neoplasms can be either
cancerous or noncancerous.
 | 10

What are Neoplasms?

Neoplasms are abnormal tissue growths resulting from rapid division of cells.
Also called tumors or masses, neoplasms can be either solid or fluid-filled and
may be benign or malignant.

Benign neoplasms (not cancerous): Malignant neoplasms (cancerous):

- May grow larger - Formed from abnormal cells that

divide without control
- Do not invade surrounding tissue or
spread - Often invades nearby tissues and
spreads to other parts of the body.
- Treated with surgical removal
 | 11

What are Benign Neoplasms?

A benign neoplasm is a non-malignant (non-cancerous) tumor. Examples of
commonly documented benign neoplasms include:

Epithelial tissue tumor in a gland or organ

Adenoma
Example: colon polyp

Connective tissue tumor

Fibroma
Example: uterine fibroid

Growths on the skin

Nevi
Example: mole

Tumor made of fat cells

Lipoma
Example: adenolipoma of the skin
 | 12

What are Malignant Neoplasms?

A malignant neoplasm or tumor:
Can invade nearby tissues or spread to other parts of the body (called
metastasis)
May be treated using surgery, and adjunct treatments (e.g., chemotherapy,
immunotherapy, and radiation therapy)

Neoplasm Documentation: Malignant vs. Benign Neoplasms

MALIGNANT BENIGN

Adenocarcinoma Adenoma

Liposarcoma Lipoma

Osteosarcoma Osteoma
 | 13

How are Malignant Neoplasms Described?

Malignant neoplasms are also described as primary or secondary:

Primary Original site or point of origin

Site or sites where malignancy has

Secondary spread (metastases)

Caution!
Do not confuse the term secondary referring to a metastasis, with a secondary or
additional, diagnosis. The term primary or secondary malignant neoplasm does not
indicate the sequencing order for code assignment.
 | 14

Understanding ICD-10-CM Neoplasm Coding Guidelines

Neoplasm Classification
 | 15

How are Neoplasms Classified?

ICD-10-CM Chapter 2, Neoplasms (C00-D49), CANCER DEVELOPMENT STAGES

classifies neoplasms by anatomic site and by
behavior as:
NORMAL
HYPERPLASIA
CELLS
Benign (noncancerous)
Malignant (cancerous)
In situ (in original place) CANCER
DYSPLASIA
IN SITU
Uncertain behavior
Unspecified behavior

INVASIVE
Code blocks within each behavior subsection CANCER
are arranged anatomically by the site involved.

Coding Note
Uncertain behavior is used when the neoplasm behavior cannot be determined
pathologically. Unspecified behavior is used when the behavior is not stated.
 | 16

Neoplasm Classification
Neoplasms are classified on the basis of the following characteristics:

Histologic Site Cell type

(anatomical location, (morphology, Acuity
Behavior topography) histology, cytology)

Primary Specific body Carcinoma Acute or chronic

malignancy site or part
Lymphoma Not achieved
Secondary Tissue type: remission
malignancy Melanoma
(metastases) - Connective In remission
Mesothelioma
- Skin In relapse
Benign Mast cell
- Neuro-
In-situ endocrine Recurrent
Leukemia
Uncertain - Lymphatic History of
Osteosarcoma
- Hematopoietic
Unspecified
 | 17

Neoplasm Classification: Staging and Grading

Clinically, the stage and grade of a tumor are directly linked to prognosis.

Stage Grade
Severity based on the size Based on cell abnormality
and how far it has spread (differentiation)

Done upon diagnosis for Higher-grade indicates

treatment planning worse prognosis

Coding Note:
It is appropriate to use the completed cancer staging form for coding purposes
when it is authenticated by the attending physician.

Source: American Hospital Association: Coding Clinic for ICD-10-CM: Documentation Issues from Coding Clinic. First Quarter 2014, Chicago, The Association.
 | 18

Understanding ICD-10-CM Neoplasm Coding Guidelines

Neoplasm Documentation
 | 19

How are Neoplasms Documented?

Detailed provider documentation of neoplastic
disease is required for complete, accurate neoplasm
reporting, including:

Anatomical location
Behavior or cell type
Metastatic sites
Related conditions
Treatment
Complications

For malignant neoplasms, identify the primary

site and any secondary (metastatic) sites. Look
for documentation of the spread "from" the
primary "to" the secondary site.
 | 20

Neoplasm Documentation

The term "mass" is not a neoplastic growth.

Do not code "mass" or lump" from the
Neoplasm Table.

The ICD-10-CM Index, under the main term "lump, directs the coder to see Mass.
If there is no index entry for the specific site under "mass" the Alphabetic Index
directs the coder to see Disease by site.

Coding Note:
Diagnoses documented as growth, new growth, neoplasm, or tumor without
further specification, are coded to D49.-. Category D49 classifies neoplasms of
unspecified morphology and behavior by site.
 | 21

Neoplasm Documentation: Related Conditions

Conditions related to neoplasms must be documented by the provider and linked

to the neoplasm. Look for terms such as "due to," "secondary to," "caused by,"
or "resulting from" that connect the neoplasm with associated conditions or
complications.

For example:
Anemia due to adenocarcinoma of the colon
Diabetes mellitus secondary to pancreatic carcinoma
Pathological fracture resulting from metastatic stage 4 ovarian carcinoma

Coding Note:
Code assignment is based on the providers documentation of the relationship
between a condition and the underlying neoplastic disease.
 | 22

Neoplasm Documentation: Treatment

Look for documentation of chemotherapy, radiation, or
immunotherapy, and conditions caused by treatments
which may require evaluation, monitoring, treatment, or
hospitalization.

For example:
Immunotherapy for cancer of the prostate
Anemia as an adverse effect of radiation therapy
Intravenous rehydration for dehydration due to
malignancy

Coding Note:
When coding surgical removal of a neoplasm followed
by adjunct chemotherapy or radiation treatment during
the same episode of care, the code for the neoplasm
should be assigned as principal or first-listed diagnosis.
 | 23

Neoplasm Documentation: Complications of Care

Complications can result from neoplastic disease or from its treatment.
Code assignment is based on the providers documentation of the relationship between
the condition and the underlying neoplastic treatment (such as side effects caused by
or resulting from therapy).

Coding Note:
Provider documentation of a cause-and-effect relationship between the care provided
and the condition, and documentation indicating it is a complication, is required for
code assignment. Query the provider if the complication is not clearly documented.
 | 24

Understanding ICD-10-CM Neoplasm Coding Guidelines

Neoplasm Coding in ICD-10-CM

 | 25

Neoplasm Coding in ICD-10-CM

ICD-10-CM Chapter 2 contains codes for most benign and all malignant neoplasms.
Certain benign neoplasms are located in the specific body system chapters (for
example prostatic adenomas). In order to code neoplasm in ICD-10-CM:

1. Determine the location of the neoplasm on the body

2. Determine whether the neoplasm is:
Benign
In-situ
Malignant, or
Of uncertain histologic behavior
3. If malignant, determine if there are any secondary (metastatic) sites.

Coding Note:
When the histological term or a descriptor such as malignant, benign, in situ, is
not documented, consult the Index under Neoplasm, then by site.
 | 26

ICD-10-CM Neoplasm Coding: Step 1

First, reference the histological term in the

Alphabetic Index to determine the appropriate
column in the Neoplasm Table (i.e., benign,
malignant, in situ, or uncertain behavior).

If the histology is not documented, consult the

index for instructional notes following the main
term, such as:

see Neoplasm, malignant, by site or

see also Neoplasm, uncertain behavior,

by site

Lets look at an example

 | 27

ICD-10-CM Neoplasm Coding - Example

If adenoma is documented in the medical record, the instructional note in the
Index directs the coder to see also Neoplasm, by site, benign.

Coding Note:
The index guidance is overridden when a descriptor is documented. For example,
malignant adenoma of colon is coded to C18.9 rather than D12.6 because the
adjective "malignant" overrules the Index direction to see benign neoplasm.

Source: ICD-10-CM Index 2016

 | 28

ICD-10-CM Table of Neoplasms

The Table of Neoplasms, in the Alphabetic Index, lists the codes for neoplasms by
anatomical site. For each site, there are six columns of codes identifying whether the
neoplasm is malignant, benign, in situ, uncertain or unspecified behavior.

Documentation often indicates which

column is appropriate, for example:
Malignant melanoma of skin
Benign fibroadenoma of breast
Carcinoma in situ of cervix uteri

Coding Note:
In the neoplasm table, a dash at the end of a code indicates an additional character is
needed (e.g., laterality). The tabular list must be reviewed for the complete code.
 | 29

Neoplasm Coding: ICD-10-CM Neoplasm Table

Certain neoplasms (such as malignant melanoma) cannot be assigned from the

Neoplasm Table. The morphological term must be indexed to find the appropriate code.

For example:
Merkel cell tumor see Carcinoma,
Merkel cell

Carcinoma, merkel cell C4A.9

Coding Note:
For connective tissue neoplasms (such as blood vessel, fascia, tendon, ligament,
muscle, nerves and ganglia, synovia), refer to the index main term Connective
tissue, then by site. Morphological types that indicate connective tissue appear in the
alphabetic index with the instruction "see Neoplasm, connective tissue.
 | 30

Understanding ICD-10-CM Neoplasm Coding Guidelines

Neoplasm Coding Guidelines

 | 31

Neoplasm Coding Guidelines

The ICD-10-CM Official Guidelines for Coding and Reporting for Chapter 2
contain many guidelines for coding and sequencing of neoplasms

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016

 | 32

Neoplasm Coding Guidelines: Principal Diagnosis

When coding neoplasms, both the general coding guidelines and the chapter specific
guidelines must be applied. Code the condition for which the encounter or service is
being performed as the first-listed or principal diagnosis.

When a patient with a primary neoplasm with

metastasis is admitted, and treatment is directed
Guideline toward the secondary site only, the secondary
neoplasm is designated as the principal diagnosis
even though the primary malignancy is still present.

Coding Note:
Additional diagnoses are reported for any other conditions that coexist at the time of
admission or develop subsequently, or which impact the patients care.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 a. and b.
 | 33

Neoplasm Coding Guidelines: Examples

Patient admitted with cancer of the

Patient admitted with breast cancer
trachea with metastasis to the cervical
with metastasis to the bones. A
lymph nodes. The primary site of the
mastectomy is performed and the
trachea is monitored and the affected
secondary sites are evaluated.
lymph nodes are resected.

The primary malignancy of the The secondary metastatic site

breast will be the principal (cervical lymph nodes) is the
diagnosis. principal diagnosis.
The secondary site of the bone The primary site (trachea) is
is coded as an additional coded as an additional
diagnosis. diagnosis.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 a. and b. and Section I.C.2.l. 1 and 2.
 | 34

Neoplasm Coding Guidelines: Current or Personal History?

Assign the code for the primary malignancy until treatment is completed. This
applies even when the primary malignancy has been excised but further treatment
(e.g., radiation therapy, chemotherapy, or additional surgery) is directed to that site.

When a primary malignancy has been excised or

eradicated and there is no further treatment of the
malignancy to that site, and no evidence of any
Guideline
existing primary malignancy, a code from category
Z85, Personal history of malignant neoplasm, is
used to indicate the former site of the malignancy.

Coding Note:
Dont confuse personal history with in remission. Codes for leukemia, multiple
myeloma, and malignant plasma cell neoplasms indicate whether the condition has
achieved remission.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2.m and n
 | 35

Neoplasm Coding Guidelines: Examples

Patient admitted to rule out metastatic

Patient with leukemia documented as
bone cancer originating from the breast.
"in remission" is admitted for
The breast cancer was treated with
autologous bone marrow
mastectomy and adjunct chemotherapy
transplantation.
3 years ago.

Report the code for

Use the appropriate code to
Personal history of designate the type of leukemia
malignant neoplasm of and in remission.
breast (Z85.3)

Coding Note:
Assign a code for personal history of leukemia when the physician documents that the
leukemia no longer exists. The codes for personal history and in remission are only
assigned when the documented by the provider.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 a. and b. and Section I.C.2.
 | 36

Neoplasm Coding Guidelines: Reason for Care

To code neoplasms, the reason for the medical care must be correctly identified.
For example, was the encounter or admission for:

? Therapy (chemotherapy, immunotherapy, radiation therapy)

? Pain control/management
? Treatment of a complication resulting from surgery or care
? Aftercare following surgery for neoplasm
? Follow-up care for completed treatment of a malignancy
? Prophylactic organ removal for prevention of malignancy
 | 37

Neoplasm Coding Guidelines: Therapy

When the patient is admitted solely for the administration of chemotherapy,

immunotherapy, or radiation therapy, the therapy is listed as the principal
diagnosis, with an additional code for the neoplasm.

For example:
Z51.0 Encounter for antineoplastic radiation therapy
Z51.11 Encounter for antineoplastic chemotherapy
Z51.12 Encounter for antineoplastic immunotherapy
 | 38

Coding Guideline: Neoplasm Related Pain

Neoplasm related pain may occur as a result of cancer surgery or chemotherapy

and radiation therapy, or because of the neoplastic disease itself.

When pain is documented as being related to, associated with, or due to

cancer, code G89.3, Neoplasm-related pain (acute) (chronic), is assigned.

Coding Note:
The inclusion terms under code G89.3 list cancer-associated pain, pain due to
malignancy (primary) (secondary), and tumor-associated pain.
Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.6.b.5
 | 39

Neoplasm-Related Pain Coding Guidelines

Reason for care documented as: Coding guideline:

Code G89.3 is assigned to pain documented as

Pain due to malignancy, cancer
being related, associated or due to cancer, primary
associated pain, tumor associated pain
or secondary malignancy, or tumor

Acute neoplasm-related pain Code G89.3 is assigned regardless of whether the

Chronic neoplasm-related pain pain is acute or chronic.

Code G89.3 is assigned as the principal or first-

Neoplasm-related pain control or
listed code and the underlying neoplasm is
management
reported as an additional diagnosis.

Code the neoplasm as the principal or first-listed

Management of the neoplasm and diagnosis and code G89.3 as an additional
neoplasm-related pain diagnosis. An additional code for the site of the
pain is not necessary.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 h. and Section I.C..6.b.5
 | 40

Applying the Neoplasm Coding Guidelines

How should this admission be coded?

A patient with metastatic bone cancer originating

from breast cancer that was eradicated 3 years ago,
is admitted for pain management.
 | 41

Applying the Neoplasm Coding Guidelines

A patient with metastatic bone cancer originating from breast cancer that
was eradicated 3 years ago, is admitted for pain management.

G89.3 Neoplasm-related pain (acute) (chronic)

C79.51 Secondary malignant neoplasm of bone
Z85.3 Personal history of malignant neoplasm of breast

Coding Note:
When the reason for the admission/encounter is management of the neoplasm
and the pain associated with the neoplasm, code G89.3 is assigned as an
additional diagnosis.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 h. and Section I.C..6.b.
 | 42

Applying the Neoplasm Coding Guidelines

How should this admission be coded?

A patient with metastatic bone cancer originating from

breast cancer that was eradicated 3 years ago, is
admitted for external beam of radiation to the affected
bone and implantation of a spinal cord neurostimulator
for control of chronic neoplasm-related pain.
 | 43

Applying the Neoplasm Coding Guidelines

A patient with metastatic bone cancer originating from breast cancer that
was eradicated 3 years ago, is admitted for external beam of radiation to
the affected bone and implantation of a spinal cord neurostimulator for
control of chronic neoplasm-related pain.

C79.51 Secondary malignant neoplasm of bone

G89.3 Neoplasm-related pain (acute) (chronic)
Z85.3 Personal history of malignant neoplasm of breast

Coding Note:
When a procedure to treat the underlying condition and a neuro-stimulator is
inserted for pain control during the same admission, a code for the underlying
condition should be assigned as the principal diagnosis and the appropriate
pain code should be assigned as a secondary diagnosis.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 h. and Section I.C..6.b.
 | 44

Understanding ICD-10-CM Neoplasm Coding Guidelines

Coding Complications
 | 45

Neoplasm Coding Guidelines: Complications

For complications associated with a malignancy or with the therapy for a malignancy,
provider documentation of the treatment and a link to the condition is needed for code
assignment.

If a patient admitted for radiation therapy, chemotherapy, or immunotherapy

develops a complication, the code for the therapy (Z51.0, Z51.11, or Z51.12) is
listed as the principal diagnosis, and code(s) for the complications are reported as
additional codes, along with the code for the neoplasm.

ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2.e.3
 | 46

Applying the Neoplasm Coding Guidelines

How should this admission be coded?

A patient with diffuse large B-cell lymphoma

throughout the lymph nodes is admitted for
chemotherapy and develops uncontrolled nausea
and vomiting.
 | 47

Applying Neoplasm Coding Guidelines

A patient with diffuse large B-cell lymphoma throughout the lymph nodes
is admitted is admitted for chemotherapy and develops uncontrolled
nausea and vomiting.

Z51.11 Encounter for antineoplastic chemotherapy

C83.38 Diffuse large B-cell lymphoma, lymph nodes of multiple sites
R11.2 Nausea with vomiting, unspecified

Coding Note:
When a patient is admitted for radiotherapy, immunotherapy or chemotherapy and
develops complications such as uncontrolled nausea and vomiting, the Z51.- code is
the principal or first-listed followed by codes for the complication(s) and the neoplasm.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 l.4
 | 48

Neoplasm Coding Guidelines: Complications

When treatment is only for management of a complication associated with a
neoplasm, the complication is coded first, followed by the appropriate code(s) for
the neoplasm.

For example:
Admission is for the management of dehydration due to malignancy, the
dehydration is listed as the principal diagnosis, with the malignancy coded
as an additional diagnosis.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2.c.3
 | 49

Applying the Neoplasm Coding Guidelines

How should this admission be coded?

A patient with acute lymphoblastic leukemia and

symptoms of dehydration is
admitted for rehydration via intravenous fluids.
 | 50

Applying Neoplasm Coding Guidelines

A patient with acute lymphoblastic leukemia and symptoms of dehydration, is

admitted for rehydration via intravenous fluids.

E86.0 Dehydration
C91.00 Acute lymphoblastic leukemia, not having achieved
remission

Coding Note:
Dehydration (E86.0) is sequenced first followed by a code for the leukemia. Reference
the main index term Leukemia, subterm acute lymphoblastic (C91.0-). The 0 is added
to indicate remission was not achieved.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 a. and b. and Section I.C.2.
 | 51

Neoplasm Coding Guidelines: Complications

GUIDELINE: When treatment is for management of a complication associated

with a neoplasm (e.g., dehydration) only, code the complication
first, followed by the code(s) for the neoplasm.

EXCEPTION: Anemia

When the treatment is only for management of anemia associated with the
malignancy, the appropriate code for the malignancy is sequenced as the principal
or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2.c.2
 | 52

Neoplasm Coding Guidelines: Anemia

Treatment of anemia Treatment of anemia that is an

associated with the adverse effect of chemotherapy
malignancy: or immunotherapy:

The malignancy code is The anemia code is sequenced

sequenced as the principal or first followed by the codes for the
first-listed diagnosis followed by neoplasm and adverse effect of
the appropriate code for the antineoplastic and
anemia. immunosuppressive drugs.

Coding Note:
The code for the adverse effect of antineoplastic and immunosuppressive drugs
requires a 7th character to indicate the encounter: A for initial encounter, D for
subsequent encounter, or S for sequela.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2.c
 | 53

Applying the Neoplasm Coding Guidelines

How should this admission be coded?

A patient with aplastic anemia due to chemotherapy

treatments for ovarian cancer, is admitted for
transfusions of packed cells for the anemia.
 | 54

Applying the Neoplasm Coding Guidelines

A patient with aplastic anemia that is due to chemotherapy treatments for ovarian
cancer is admitted for transfusions of packed cells for the anemia.

D61.1 Drug-induced aplastic anemia

C56.9 Malignant neoplasm of unspecified ovary
T45.1X5A Adverse effect of antineoplastic and
immunosuppressive drugs, initial encounter

Coding Note:
The adverse effect code is located by referencing the Table of Drugs and Chemicals
under the substance main term Antineoplastic NEC under the column for adverse
effects. The A is added to indicate an initial encounter.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 c.
 | 55

Neoplasm Coding Guidelines: Surgical Complications

Many patients with malignant neoplasms undergo surgical procedures to treat the
malignancy. Complications of these procedures may result.

If the patient is admitted for management and treatment directed at resolving a

complication that resulted from a surgical procedure:

The complication is designated as the principal diagnosis.

The malignant neoplasm is listed as an additional code.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2.c.4
 | 56

Applying the Neoplasm Coding Guidelines

How should this admission be coded?

A patient treated with surgery and radiation therapy

for carcinoma of the body of the stomach is
readmitted for drainage of a hematoma of the skin at
the surgical site.
 | 57

Applying the Neoplasm Coding Guidelines

A patient treated with surgery and radiation therapy for carcinoma of

the body of the stomach is readmitted for drainage of a hematoma of
the skin at the surgical site.

L76.22 Postprocedural hemorrhage and hematoma of skin and

subcutaneous tissue following other procedure
C16.2 Malignant neoplasm of the body of stomach

Coding Note:
When the admission/encounter is for treatment of a complication resulting from a
surgical procedure, sequence the complication as the principal or first-listed diagnosis
if treatment is directed at resolving the complication.

Source: ICD-10-CM Official Guidelines for Coding and Reporting 2016; Section I.C.2 a. and b. and Section I.C.2.
 | 58

Wrap Up
Thank you for attending our webinar!

In this webinar we:

Examined the classification of neoplastic disease in ICD-10-CM Chapter 2:
Neoplasms (C00-D49) and how to locate codes for neoplasms using the Index and
the Neoplasm Table.
Identified the terminology used in the medical record to describe neoplastic disease
and the documentation needed to properly code neoplasms
Practiced applying the chapter-specific guidelines, coding conventions, and
sequencing rules while assigning ICD-10-CM neoplasm codes.

Elsevier Revenue Cycle eLearning www.icd-10online.com/

 | 59

References
National Center for Health Statistics, Centers for Disease Control
and Prevention: ICD-10-CM Guidelines for Coding and Reporting,
2016. Accessed September 29, 2015:
www.cdc.gov/nchs/icd/icd10cm.htm#10update

National Center for Health Statistics, Centers for Disease Control

and Prevention: ICD-10-CM Tabular List of Diseases and Injuries,
2016. Accessed September 29, 2015:
www.cdc.gov/nchs/icd/icd10cm.htm#10update

Centers for Medicare and Medicaid Services: 2016 ICD-10-CM and

GEMs. Accessed September 29, 2015:
http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-
GEMs.html