When coding for a neoplasm where should you look first?

9). The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

How are neoplasms classified for coding?

In ICD-10-CM, neoplasms are classified primarily by site (anatomic location, topography) and behavior (malignant, benign, carcinoma in situ, uncertain behavior and unspecified).

When do you code neoplasm of uncertain behavior?

Uncertain has a specific meaning in ICD-10. It means that the specimen has been examined by the pathologist and it can’t be determined if the neoplasm is benign or malignant. An uncertain neoplasm is reported after the pathologist’s report, not when sending the specimen for biopsy.

Can you code a mass as a neoplasm?

The words “MASS” or “LUMP” should NEVER be coded using the Neoplasm Table. When searching for the main term “lump,” the Alphabetic Index of the ICD-10 book directs the coder to see “Mass.”

How is malignant neoplasm diagnosed?

How is malignant neoplasm diagnosed? Your healthcare provider may suspect cancer after performing a routine test, such as a mammogram or colonoscopy. In most cases, a biopsy is needed to determine if the tumor is benign (noncancerous) or malignant (cancerous).

When coding malignant neoplasms the primary site is?

Malignant neoplasms of ectopic tissue are to be coded to the site where they are found e.g. ectopic pancreatic malignant neoplasms of ovary are coded to ovary (C56), as per Tabular List note 6 at C00-D48.

What is a neoplasm and how are neoplasms classified?

A neoplasm is an abnormal growth of cells in the body, also described as a tumor. A neoplasm can be a small growth, such as a mole, or a cancerous or pre-cancerous tumor. Most of the time, neoplasms are not dangerous to your health, but they can be.

What is a neoplasm of uncertain behavior?

When the behavior of a tumor cannot be predicted through pathology, it is called a neoplasm of uncertain behavior. These are neoplasms which are currently benign but have characteristics that make it possible for the tumor to become malignant.

How do you code a neoplasm?

To properly code a neoplasm, it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant or of uncertain histologic behavior. If malignant, any secondary ( metastatic) sites should also be determined. All neoplasms are classified in this chapter, whether they are functionally active or not.

What is the neoplasm chapter in a biopsy?

The neoplasm chapter contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms such as prostatic adenomas maybe found in the specific body system chapters. To properly code a neoplasm, it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant or of uncertain histologic behavior.

What is the neoplasm table and how is it used?

The Neoplasm Table gives the code numbers for neoplasm by anatomical site. For each site there are six possible code numbers according to whether the neoplasm in question is malignant, benign, in-situ, of uncertain behavior or of unspecified nature. When such descriptors are not present, the reminder of the alphabetical index should be consulted.

What is the classification of neoplasms?

Classification of neoplasms is primarily by site (topography) with broad groupings for behavior, malignant, in situ, benign, etc. The Table of Neoplasms should be used to identify the correct topography code.