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April 5, 2004

Coding for Head and Neck Cancer
Vol. 16 No. 7 p. 37

Head and neck cancer is malignant tumors of areas in the head and neck with the exception of brain tumors. Sometimes referred to as throat cancer, it accounts for 3% to 5% of all cancers in the United States. The most common cause of head and neck cancer is the excessive use of tobacco (including smokeless tobacco) and alcohol. Other risk factors include sun exposure to lips, radiation to head and neck, nickel dust inhalation, and exposure to asbestos.

Head and Neck Cancer Sites
Cancers of the head and neck are further identified by the tumor location. The following include some specific locations with the ICD-9-CM code classification in parentheses:
• Oral cavity includes lips (140.x), front two-thirds of the tongue (141.1-141.4), gums (143.x), buccal mucosa (145.0), floor of mouth under the tongue (144.x), hard palate (145.2), and the small area behind the wisdom teeth called retromolar trigone (145.6)
• Salivary glands (142.x) are located under the tongue (sublingual gland), in front of the ears (parotid gland), and in the floor of the mouth (submandibular gland)
• Paranasal sinuses (160.2-160.5)
• Nasal cavity (160.0)
• Nasopharynx (147.x), which is the upper part of the throat behind the nose
• Oropharynx (146.x), which is the middle part of the throat that is behind the mouth and includes the soft palate (145.3), base of tongue (141.0), and tonsils (146.0)
• Hypopharynx (148.x) includes the lower part of the throat
• Larynx (161.x) contains vocal cords and epiglottis
“X” denotes that a fourth-digit subcategory is required to further classify the specified site of the malignancy.

Code 195.0 is assigned when a primary site head and neck malignant neoplasm is diagnosed but the point of origin cannot be determined. Sometimes, cancer is found in the lymph nodes of the upper neck (196.0) when there is no evidence of cancer in other parts of the head and neck. This is called metastatic neck cancer with unseen (occult) primary.
Most head and neck cancers are squamous cell carcinomas, which are tumors that develop in the tissues lining the hollow organs of the body.

Symptoms
Common symptoms of head and neck cancer include the following:
• Lump in neck that does not go away
• Mouth or throat sore that does not heal
• Persistent pain in the throat
• Difficulty swallowing
• Persistent hoarseness in voice or change in voice
• Neck or jaw pain that radiates to the ear
• Bleeding in the mouth or throat
• Coughing up blood
• White (leukoplakia) or red (erythroplakia) patch on gums, tongue, or lining of mouth

Diagnosis
To aid in the diagnosis of head and neck cancer, the physician will perform a complete physical examination to detect lumps. The physician may also perform the following diagnostic tests:
• Endoscopy such as laryngoscopy, esophagoscopy, and nasopharyngoscopy, depending on the site of the possible cancer
• Blood and urine laboratory tests
• X-rays of head and neck
• Computed tomography scan of head and neck
• Magnetic resonance imaging of head and neck
• Biopsy, which is the only definite method to determine whether or not a patient has cancer

Staging
The staging process determines the extent of the cancer and whether or not it has spread. It assesses the patient’s prognosis and determines the choice of therapy. The TNM staging method is used, which includes:
• T — size of the primary tumor
• N — degree of which regional lymph nodes are involved
• M — presence or absence of distant metastases

Once TNM is determined, the stage is assigned, which includes the following:
• Stage I — cancers are small, localized, and usually curable
• Stage II and III — cancers are typically locally advanced and/or have spread to local lymph nodes
• Stage IV — cancers are usually metastatic and considered inoperable

Recurrent cancer is when cancer returns or develops again after all visible evidence of a tumor has been eradicated through treatment. Locally recurrent recurs at the area of the original or primary tumor. Distant recurrence recurs as metastases. According to coding guidelines, recurrent primary cancer (locally recurrent) is coded as a primary malignancy of the stated site (AHA Coding Clinic for ICD-9-CM, 1985, May-June, pages 9-12). If the cancer recurs as metastases, assign a metastatic code for the specified site.

Treatment
The treatment plan depends on the exact location, stage of cancer, and overall health and age of the patient. The following treatment methods may be used alone or in combination:
• Surgery to remove cancer and area lymph nodes. This may change the patient’s ability to chew, swallow, or talk. Code assignment depends on specific procedure performed and site of cancer.
• Radiation therapy may be internal, which includes radioactive materials inserted directly into or near cancer (92.27), or external from a machine outside the body.
• Chemotherapy (99.25). Some drugs used may include cisplatin, fluorouracil, carboplatin, and paclitaxel.

Coding and sequencing for head and neck cancer are dependent upon 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 Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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