January 28, 2013

Coding for Ovarian Cancer
For The Record
Vol. 25 No. 2 P. 26

Ovarian cancer is a type of gynecological cancer that originates in the ovaries. Unfortunately, it may not be diagnosed until it has progressed to a more advanced stage because it rarely causes symptoms in the early stages. Therefore, the prognosis is not as favorable since it’s more difficult to treat ovarian cancer in its later stages.

Types of Ovarian Cancer
The cell where the cancer begins determines the type of ovarian cancer and may include the following:

• Epithelial tumor: begins in the thin layer of tissue that covers the outside of the ovaries;

• Germ cell tumor: begins in the egg-producing cells and occurs more commonly in younger women; and

• Stromal tumors: originates in ovarian tissue that produces the hormones estrogen, progesterone, and testosterone.

Ovarian cancer is assigned to ICD-9-CM code 183.0, Malignant neoplasm of ovary. It’s also appropriate to code any functional activity, such as one of the following:

• other ovarian dysfunction (256.8);

• hirsutism (704.1);

• hyperestrogenism (256.0);

• other ovarian hyperfunction (256.1);

• precocious sexual development and puberty (259.1); and

• adrenogenital disorders (255.2).

Code 233.39 is used for carcinoma in situ of the ovary. If the ovarian tumor is documented as benign, assign code 220, Benign neoplasm of ovary. Code 220 also includes neoplastic cyst of ovary. Other types of ovarian cysts are classified as follows:

• chocolate cyst (617.1);

• corpus luteum cyst (620.1);

• congenital ovarian cyst or hematoma (752.0);

• endometrial cyst (617.1);

• follicular cyst (620.0); and

• ovarian cyst, not otherwise specified (620.2).

Symptoms
The most common signs and symptoms of ovarian cancer include abdominal swelling and bloating; increased abdominal girth; pelvic discomfort, pain, pressure, or heaviness; abnormal bleeding or discharge; indigestion, gas, or nausea; constipation; urinary frequency; loss of appetite or feeling full quickly; lack of energy; and lower back pain.

Diagnosis
The physician may choose to do one or a combination of the following diagnostic tests to evaluate the patient to confirm a diagnosis of ovarian cancer:

• Pelvic examination to feel for ovarian or abdominal mass;

• CA 125 blood test because it may be elevated in patients with ovarian cancer (This is not a reliable test, as many other conditions may cause elevated CA 125 in the blood. In addition, patients in the early stages of ovarian cancer may have normal levels of CA 125.);

• pregnancy test;

• abdominal or pelvic CT or MRI;

• pelvic ultrasound; or

• biopsy.

Treatment
Treatment for ovarian cancer typically involves both surgery and chemotherapy. The surgery will involve removing the ovaries, fallopian tubes, uterus, and possibly surrounding lymph nodes. The surgeon also may perform debulking, which is the removal of as much of the cancer as possible. The code assignment for debulking will depend on the site of tissue removal and whether the tissue was removed by destruction or excision. It’s possible to assign more than one code for the procedure depending on the structure(s) operated on. Therefore, thorough review of the operative report is necessary for appropriate code assignment.

Code assignment for removal of the fallopian tubes (salpingectomy) and ovaries (oophorectomy) depends on whether the procedure was unilateral, bilateral, open, or laparoscopic and whether the tubes and ovaries were both removed or if only the tubes or the ovaries were excised. Review the table below for appropriate code assignment:

Notice that there are no specific code assignments for laparoscopic salpingectomy. Therefore, the code assignment defaults to the open approach. If the procedure was performed with robotic assistance, assign one of the following procedure codes as a secondary procedure:

• 17.41, Open robotic assisted procedure; or

• 17.42, Laparoscopic robotic assisted procedure.

Principal Procedure
Procedures performed to treat ovarian cancer may require more than one code to completely classify the operations performed. According to the AHA Coding Clinic for ICD-9-CM, fourth quarter, 2012, the following guidelines should be followed when selecting the principal procedure:

• When two procedures are performed for the definitive treatment of both the principal diagnosis and a secondary diagnosis, sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure.

• When procedures are performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis, sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure.

• When a diagnostic procedure is performed for the principal diagnosis and another procedure is performed for definitive treatment of a secondary diagnosis, sequence the diagnostic procedure most related to the principal diagnosis as the principal procedure. The procedure—either diagnostic or definitive—most related to the principal diagnosis takes precedence.

• When definitive and diagnostic procedures performed are related only to the secondary diagnoses, with no procedures related to the principal diagnosis, sequence the procedure performed for definitive treatment related to the secondary diagnosis as the principal procedure.

This Coding Clinic has made it clear that the procedure most related to the principal diagnosis should be sequenced as the principal procedure, which is not necessarily the procedure that represents the most definitive treatment. Therefore, if a patient is admitted for a total abdominal hysterectomy with bilateral salpingo-oopherectomy (BSO) because of ovarian cancer, the code for the BSO (65.61) should be sequenced as the principal procedure. The BSO is more related to the principal diagnosis (ovarian cancer) than the hysterectomy is.

Coding and sequencing for ovarian cancer are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

ICD-10-CM/PCS Coding for Ovarian Cancer
In ICD-10-CM, malignant neoplasms of female genital organs are specific to sections of the organ (eg, cervix uteri, endocervix, exocervix, corpus uteri, isthmus uteri, endometrium, myometrium, fundus, uteri, ovary, right or left). The ICD-10-CM code assignments for ovarian cancer are as follows:

• C56.1, Malignant neoplasm of right ovary;

• C56.2, Malignant neoplasm of left ovary; and

• C56.9, Malignant neoplasm of unspecified ovary.

To appropriately assign the procedure codes in ICD-10-PCS, the operative report must identify each body part removed. In addition, the removal of ovaries and tubes must be specified as right, left, or bilateral. The root operation for a complete removal is resection, which is defined as “cutting out or off, without replacement, all of a body part.” The approach may include one of the following:

• open;

• percutaneous endoscopic;

• via natural or artificial opening;

• via natural or artificial opening endoscopic; or

• via natural or artificial opening with percutaneous endoscopic assistance.

Therefore, the appropriate code assignment for an open bilateral salpingo-oopherectomy in ICD-10-PCS is 0UT20ZZ and 0UT70ZZ. Both codes are required because the ovaries and fallopian tubes are considered two separate body parts.

— AH