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Let provider ocumentation guide you to the correct number of codes.

As an oncology coder, you know just how important it is to ensure your diagnosis codes are specific, as unspecified or inaccurate codes could jeopardize patient outcomes and payer reimbursement. But sometimes, a patient鈥檚 discharge summary, progress notes, history, and physical are unclear, making coding almost impossible.

When that happens, however, you don鈥檛 have to resort to an unspecified code. In her HEALTHCON 2025 presentation, 鈥淗ot Topics in Oncology,鈥� Stephanie Thebarge, compliance manager at New England Cancer Specialists, explained why, and offered a solution and some sage advice to help you easily pin down a specific code quickly and easily.

Understand the Problem

Consider the following scenario based on a question submitted to AHA ICD-10 Coding Clinic (2012 Vol. 29, No. 2): Can you assign a secondary diagnosis code for lymph node metastasis when the provider has documented staging of T4N1 for a diagnosis of squamous cell carcinoma of the cervix?

If you answered in the affirmative with C77.5 (Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes), you would be absolutely correct. But the reason why C77.5 happens to be correct is important, as it provides you with a powerful tool in your cancer coding arsenals.

Get to Know Staging Classifications

The reason why C77.5 is correct in the above scenario is because the code is derived from documentation of the cancer鈥檚 staging, 鈥渁 standardized way of describing the extent of cancer in a patient鈥檚 body,鈥� according to Thebarge. As it describes cancer severity, the system allows you to bypass an unspecified code in favor of using 鈥渢he completed cancer staging form for coding purposes when it is authenticated by the attending physician,鈥� per AHA ICD-10 Coding Clinic (2010 Vol. 27, No. 2).

The staging classification system consists of letters and numbers a provider assigns to describe the progress of a patient鈥檚 cancer in three specific categories: tumor size and spread, node involvement, and metastasis. The system is more readily known by its acronym TNM, (鈥渢he 鈥楳鈥� is the big one,鈥� Thebarge noted). When a physician uses this system, they assign numbers after each of the letters in the TNM system:

Primary or main tumor (T)

• TX: Main tumor cannot be measured
• T0: Main tumor cannot be found
• T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the more it has grown into nearby tissues. Ts can be further divided for more detail such as T3a, etc.

Regional lymph nodes (N)

• NX: Cancer in nearby lymph nodes cannot be measured
• N0: There is no cancer in nearby lymph nodes
• N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. The higher the number after the N, the more lymph nodes that are affected.

Distant metastasis (M)

• MX: Metastasis cannot be measured
• M0: Cancer has not spread to other parts of the body
• M1: Cancer has spread to other parts of the body

Complete the Original Example 鈥�

So, going back to our original example, designating the patient鈥檚 squamous cell carcinoma of the cervix as T4N1 tells you the patient鈥檚 primary cancer, the squamous cell carcinoma of the cervix (T), is so large (4) it has started to affect local primary nodes (N1). The absence of an M classification means the cancer has not metastasized to other parts of the body, however.

This means the patient has both a primary cancer, coded to C53.0 (Malignant neoplasm of endocervix), and secondary involvement in local lymph nodes, coded to C77.5 as we have already seen.

Solve This Second One

The provider documents breast cancer of the upper outer quadrant of the patient鈥檚 left breast, staged as T2. In this situation, you have all the information you need to code C50.412 (Malignant neoplasm of upper-outer quadrant of left female breast). But the information tells you that鈥檚 the only code you should assign in this situation. That鈥檚 because the provider has documented that the breast cancer is in stage 2 (meaning it is early and has not advanced to the lymph nodes or elsewhere in the body). In this example, no other codes are necessary.

And Understand Why This Is Important

While there are occasions when assigning an unspecified code might be appropriate, for the most part, specificity will be necessary to justify medical necessity for a course of treatment. This means a diagnosis code such as C50.919 (Malignant neoplasm of unspecified site of unspecified female breast) should be avoided as much as possible. A more specific code will ensure 鈥渕ore accurate coding, better patient care, and enhanced data quality,鈥� according to Thebarge.

Additionally, for Medicare patients, coding has profound implications, as breast cancers documented as early stage 鈥渕ay correspond to a lower Hierarchical Condition Category (HCC) risk-adjustment factor, whereas late-stage or metastatic breast cancers correspond to a higher risk-adjustment score due to increased resource utilization and higher expected treatment costs,鈥� Thebarge explained.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC