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January 31, 2011

Coding for Prostate Cancer
For The Record
Vol. 23 No. 2 P. 27

Prostate cancer (ICD-9-CM code 185) occurs when cells within the prostate grow uncontrollably, creating small tumors. Adenocarcinoma is the most common type (85%) and arises from the glandular tissue within the prostate. Initially, it is confined to the prostate gland but it can metastasize. It can grow slowly, requiring minimal to no treatment or can grow fast and require extensive treatment.

Prostatic intraepithelial neoplasia (PIN) is a premalignant condition and common precursor to prostate cancer. There are three levels of PIN. PIN 1 and 2 are classified to code 602.3, Dysplasia of prostate, and PIN 3 is considered carcinoma in situ of the prostate and classified to code 233.4.

For prostatic carcinoma staging, review the pathology report as well as diagnostic studies to determine the presence of metastatic sites. Codes may not be assigned based only on the pathology report; the physician must confirm the diagnosis in the progress notes or the discharge summary before a code may be assigned.

Common symptoms of prostate cancer include bloody semen; difficulty initiating or stopping urination; frequency of urination (especially nocturnal); hematuria; pain or burning during urination; pain in the lower back, hips, or upper thighs; and a stuttering or weak urine flow.

Most cases of prostate cancer are detected during routine screening, which include prostate-specific antigen (PSA) tests or a digital rectal exam (DRE). PSA is secreted exclusively by prostatic epithelial cells. PSA levels can be helpful in detecting prostate cancer, but the PSA level may be elevated due to other conditions such as benign prostatic hypertrophy, infection (including prostatitis), or inflammation. Normal PSA levels are dependent on age and race, but broad ranges are less than 2.5 ng/mL for ages 40 to 49, less than 4 ng/mL for ages 50 to 59, less than 4.5 ng/mL for ages 60 to 69, and less than 6.5 ng/mL for ages 70 to 79.

Grading is used to determine how aggressive the cancer is. The Gleason score is the most common grading system used to determine the degree of metastasis, with Gleason scores greater or equal to 7 reflecting more aggressive tumors. An additional determination of prostate cancer is as follows:

• Stage 1: This is early cancer confined to a microscopic area and unable to be palpated by a physician via DRE.

• Stage 2: The tumor can be palpated but is still confined to prostate (in situ).

• Stage 3: The cancer has expanded beyond the prostate to the seminal vesicles or other nearby tissues.

• Stage 4: The cancer has spread to the lymph nodes, bones, or other organs.

Treatment for prostate cancer depends on how fast the cancer is growing, the stage, and the patient’s age and life expectancy. Common treatment options include: bilateral orchiectomy (62.41), chemotherapy (99.25), cryotherapy (60.62), external beam radiation therapy (92.29), prostatectomy (60.21-60.69), and radioactive seed implants or brachytherapy (92.27). Medications such as hormone therapy to decrease production of testosterone may also be used. A common medication class is luteinizing hormone-releasing hormone agonists (99.24), which include leuprolide (Lupron, Viadur) and goserelin (Zoladex). Other medications include antiandrogens, which prevent testosterone from reaching cancer cells. Examples include bicalutamide (Casodex) and nilutamide (Nilandron).

Coding and sequencing for prostate 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 Cheryl Manchenton, RN, BSN, and 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.

Coding Prostate Cancer in ICD-10

The ICD-10-CM Official Guidelines for Coding and Reporting for neoplasms is similar to the ICD-9-CM official coding guidelines with a few exceptions. Here is a summary of the ICD-10-CM neoplasm coding guidelines:

• Designate the malignancy as the principal diagnosis when the treatment is directed toward the malignancy. However, if a patient is admitted solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate Z51 code as the principal diagnosis and the malignancy as the secondary diagnosis.

• Designate the secondary-site neoplasm as the principal diagnosis when the treatment is directed toward only the secondary (metastatic) neoplasm even though the primary site is still present.

• Sequence the malignancy as the principal diagnosis when a patient is admitted for the treatment of anemia associated with a malignancy. Code D63.0, Anemia in neoplastic disease, is assigned as a secondary diagnosis. This guideline is a change from the current ICD-9-CM Official Guidelines for Coding and Reporting.

• Sequence the adverse effect code as the principal diagnosis when a patient is admitted for the treatment of anemia associated with an adverse effect of chemotherapy, immunotherapy, or radiotherapy and the treatment is only for the anemia. The codes for anemia and neoplasm should be added as secondary diagnoses.

• Sequence dehydration as the principal diagnosis when the admission is for management of dehydration due to the malignancy or the therapy and only the dehydration is being treated.

• Sequence the complication as the principal diagnosis when the admission is for the treatment of a complication resulting from a surgical procedure if treatment is directed at resolving the complication.

• Assign a code from category Z85, Personal history of primary and secondary malignant neoplasm, when the primary malignancy has been previously excised or eradicated from its site and there is no treatment directed at that site and no evidence of any remaining malignancy at the primary site. Documentation of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The metastatic site may be sequenced as the principal diagnosis if treatment is directed toward the metastatic site.

• Sequence the neoplasm as principal diagnosis when the patient is admitted for surgical removal of a neoplasm followed by chemotherapy or radiation therapy.

• If the patient is admitted solely for the purpose of receiving chemotherapy, immunotherapy, or radiotherapy, sequence code Z51.11 (Admit for chemotherapy), Z51.12 (Admit for immunotherapy), or Z51.0 (Admit for radiotherapy) as the principal diagnosis. More than one of these codes may be assigned if the patient receives more than one of the therapies.

• A code from category Z51 will be the principal diagnosis if the patient is admitted for chemotherapy, immunotherapy, or radiotherapy and develops a complication after admission.

• Sequence the malignancy (either the primary or secondary) as the principal diagnosis if the patient is admitted to determine the extent of the malignancy (staging) or for a procedure such as thoracentesis or paracentesis even though chemotherapy or radiation therapy is administered.

• Sequence the malignancy as principal diagnosis when the patient is admitted with signs and symptoms related to the malignancy.

• Assign a code for all metastatic and primary sites documented by the physician. Only assign code C80.0, Disseminated malignant neoplasm, unspecified, if the patient has advanced metastatic disease and the primary or secondary sites are not specified.

• Assign code C80.1, Malignant neoplasm, unspecified, only if the primary site neoplasm is not documented.

— AH