Some Neoplasm Q & A 

ICD-CM-10

Q. What if the documentation states malignant neoplasm, but the site is not documented?

A. Then you would code C80.1, Malignant (primary) neoplasm, unspecified. Note, this code should only be reported when no determination can be made as to the primary site of the neoplasm.

Q. What is metastatic cancer?

A. Metastatic cancer is cancer that has spread from the place where it first started (primary site) to another place in the body (secondary site). 

Q. What if the treatment is directed toward the metastatic site, how is that coded?

A. The metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.

Q. How do you code a neoplasm if the patient is pregnant?

A. See subcategory O9A.1 and sequence first, followed by a code from Chapter 2 to indicate the type of neoplasm.

Q. What if there is a complication associated with a neoplasm and the treatment is only for the complication?

A. The complication is coded first, followed by the code for the neoplasm. The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease. 2016-ICD-10-CM-Guidelines

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