March 30, 2009

Coding for Prostate Cancer
For The Record
Vol. 21 No. 7 P. 28

Prostate cancer occurs when a group of abnormal cells is found in the prostate gland. Initially, the cells will stay confined to the gland but can eventually spread or metastasize to other areas. There is a better prognosis if the cancer is detected early while still confined to the prostate gland.

Prostate cancer is assigned to ICD-9-CM diagnosis code 185. Carcinoma in situ of the prostate is classified to code 233.4, and a benign neoplasm of the prostate goes to code 222.2. If it’s documented that the neoplasm is of the seminal vesicles, assign codes 187.8 for malignant cancer, 233.6 for carcinoma in situ, and 222.8 for benign neoplasm.

Prostatic intraepithelial neoplasia (PIN) is a premalignant condition and a common precursor to prostate cancer. There are three levels of PIN: PIN 1 and PIN 2 are classified to code 602.3, Dysplasia of prostate. PIN 3 is indexed to code 233.4, Carcinoma in situ of prostate (AHA Coding Clinic for ICD-9-CM, 2001, fourth quarter, page 46).

Malignant prostate cancer may metastasize to other sites, including the bladder or urethra (198.1), bone (198.5), intrapelvic lymph nodes such as iliac or sacral (196.6), intra-abdominal (periaortic) lymph nodes (196.2), or the seminal vesicles (198.82).

Symptoms
Typically, prostate cancer does not cause any symptoms in the early stages, making it difficult to diagnosis until the cancer has spread outside the prostate. Early signs and symptoms of prostate cancer include trouble urinating, starting and stopping while urinating, a decreased force in the urine stream, and blood in urine or semen.

The urinary symptoms may be caused by benign prostatic hypertrophy (BPH; category 600). If the cancer has spread to the pelvic lymph nodes, swelling in the legs or discomfort in the pelvic area may be present. If the cancer has spread to the bone, signs and symptoms may include unrelenting bone pain, bone fracture, or compression of the spine.

Diagnosis
Most cases of prostate cancer are detected during routine screenings, including a prostate-specific antigen (PSA) test or digital rectal exam (DRE). PSA can be helpful for detecting prostate cancer but may be elevated due to other conditions such as BPH, an infection, or inflammation. If the PSA or the DRE is abnormal, the physician may perform a transrectal ultrasound, which takes pictures of the prostate through the rectum. A prostate biopsy may also be performed to confirm the presence of cancer. An open prostatic biopsy is classified to code 60.12, while a close/needle/percutaneous biopsy goes to code 60.11.

Treatment
Treatment for prostate cancer will depend on how fast the cancer grows, if it has spread, the patient’s age, and the patient’s life expectancy. Common treatment options include external beam radiation therapy and radioactive seed implants (92.27). Also called brachytherapy, several radioactive seeds are implanted in the prostate through ultrasound-guided needles. When a patient is admitted for the implantation of radioactive seeds, sequence the prostate cancer (185) as the principal diagnosis (AHA Coding Clinic for ICD-9-CM, 1988, first quarter, pages 4-5).

Hormone therapy, which decreases the body’s production of testosterone, is another option. A common drug used is luteinizing hormone-releasing hormone agonists (99.24), which include leuprolide (Lupron, Viadur) and goserelin (Zoladex). Another type is antiandrogens, which prevent testosterone from reaching the cancer cells. Examples include bicalutamide (Casodex) and nilutamide (Nilandron).

Bilateral orchiectomy (62.41) stops the production of testosterone, while a radical prostatectomy involves the removal of the prostate and nearby lymph nodes. It is appropriate to assign a code for the radical prostatectomy (60.5) and a code from category 40 to identify the type and site of lymph node dissection (AHA Coding Clinic for ICD-9-CM, 1993, third quarter, page 12). Code 60.5 should be assigned if the procedure is described as radical, regardless of the approach. If the procedure performed is not described as a radical prostatectomy, the code assignment will depend on the approach. Retropubic prostatectomy (60.4) is the removal of the prostate through an incision in the lower abdomen. Perineal prostatectomy (60.62) is the removal of the prostate through an incision between the anus and the scrotum. The surgeon is not able to remove the nearby lymph nodes through this approach.

There is also robot-assisted laparoscopic radical prostatectomy (60.5 and 17.42), chemotherapy (99.25), or cryotherapy (60.62).

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.