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April 11, 2011

Coding for Lung Cancer
For The Record
Vol. 23 No. 7 P. 27

Lung cancer is any type of malignant growth in the lungs that occurs when cells in the lung start to grow rapidly and uncontrollably. Smoking puts people at the highest risk of developing lung cancer, though exposure to secondhand smoke is also a major cause. Lung cancer is the leading cause of cancer death among both men and women.

Lung cancer does not typically produce symptoms in the disease’s early stages. When symptoms do appear in the more advanced stages, they may include the following:

• coughing (a new cough or a change in a chronic cough);

• hemoptysis;

• chest pain;

• shortness of breath;

• wheezing;

• hoarseness;

• weight loss;

• bone pain; and/or

• headache.

Types of Lung Cancer
There are two major types of lung cancer, which is determined by the appearance of the cancerous cells under a microscope:

• Small-cell lung cancer: Also called oat cell cancer, it is the more aggressive type and frequently metastasizes to other sites such as the liver, bone, and brain. It is almost always seen in smokers.

• Non–small-cell lung cancer: This is a general term that includes several types of lung cancer that behave similarly. Non–small-cell lung cancers include squamous cell carcinoma, adenocarcinoma, and large-cell carcinoma. This type of lung cancer is more common than small cell.

Regardless of the cell type, the ICD-9-CM code for primary malignant neoplasm of the lung is 162.x, with the fourth-digit subcategory identifying the specified site of the cancer such as:

• 162.0, Trachea;

• 162.2, Main bronchus;

• 162.3, Upper lobe, bronchus or lung;

• 162.4, Middle lobe, bronchus or lung;

• 162.5, Lower lobe, bronchus or lung;

• 162.8, Other parts of bronchus or lung (includes malignant neoplasm of contiguous or overlapping sites of bronchus or lung whose point of origin cannot be determined); and

• 162.9, Bronchus and lung, unspecified.

Carcinoma in situ of the lung is classified to code 231.2. Nonmalignant neoplasms of the lung are classified to code 212.3 for benign, 235.7 for uncertain behavior, and 239.1 for unspecified nature. If the lung cancer is considered a metastatic site—the cancer spread from another organ to the lung—code 197.0 is assigned.

Advanced lung cancer eventually metastasizes to nearby lymph nodes or other tissues in the chest, including the other lung. In many cases, lung cancer spreads to other organs in the body such as the bone (198.5), brain (198.3), liver (197.7), and adrenal glands (198.7).

The following exams and tests may be performed to diagnose lung cancer:

• A chest x-ray identifies an abnormal mass or nodule.

• A CT scan may reveal a small nodule not identified by chest x-ray.

• A sputum culture detects cancerous cells.

• A biopsy confirms whether cancerous cells are present. The biopsy may be performed though a bronchoscope (33.24), percutaneous needle (33.26), thoracoscopic (33.20), or open (33.28). A transthoracic needle biopsy of lung is also classified to code 33.26.

Transbronchial lung biopsy (33.27) is when the bronchoscope biopsy forceps actually punctures the terminal bronchus and samples of the peribronchial alveoli (lung tissue) are taken. The coder should read the operative report completely to determine the procedure performed prior to code assignment.

• Thoracentesis (34.91) identifies cancerous cells in the fluid of the chest cavity.

Once a lung cancer diagnosis is made, further studies are performed to determine the extent of the disease. The studies may include a CT scan, bone scan, or pulmonary angiography. Small-cell lung cancer is staged as follows:

• Limited: Cancer is confined to one lung and to its neighboring lymph nodes; and

• Extensive: Cancer has spread beyond one lung and its neighboring lymph nodes, possibly invading both lungs, more remote lymph nodes, or other organs.

Non–small-cell lung cancer is staged according to tumor size, the level of lymph node involvement, and the extent of distant metastases. Stages include the following:

• Stage I: spread to layers of lung tissue;

• Stage II: invaded neighboring lymph nodes or spread to the chest wall;

• Stage IIIA: spread from lung to lymph nodes beyond the lung area;

• Stage IIIB: spread to areas such as the heart, blood vessels, trachea, and esophagus (all within the chest); and

• Stage IV: spread to other parts of the body such as the liver, bone, and brain.

Lung cancer treatment depends on the size, location, stage, and type of cancer as well as an individual’s overall health. Surgery, radiation therapy, and chemotherapy may be used alone or in various combinations to address the cancer. Surgery may be the option of choice when the cancer is confined to a limited area. Procedures may include the following:

• Wedge resection (32.29) or thoracoscopic wedge resection (32.20) is the removal of a small portion of the affected lung. This procedure should not be confused with a wedge biopsy of the lung (33.28) or thoracoscopic wedge biopsy of lung (33.20), which is the removal of a small sample of lung tissue for microscopic examination.

• Segmental resection (32.39) or thoracoscopic segmental resection (32.30) is the removal of a small portion of the lung.

• Lobectomy (32.49) or thoracoscopic lobectomy (32.41) is the removal of the entire lobe of the lung.

• Pneumonectomy (32.59) or thoracoscopic pneumonectomy (32.50) is the removal of the entire right or left lung.

Coding and sequencing for lung 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.


Coding for Lung Biopsy in ICD-10-PCS
A biopsy of the lung is identified by the root operation of drainage, excision, or extraction based on the objective of the procedure. The root operation of drainage is defined as “taking or letting out fluids and/or gases from a body part.” The root operation of excision is defined as “cutting out or off, without replacement, a portion of a body part.” Extraction is defined as “pulling or stripping out or off all or a portion of a body part by the use of force.” The qualifier (character 7) of diagnostic will be used to identify drainage, excision, or extraction procedures that are biopsies.

The specific site of the lung biopsy (character 4) should be identified, including upper, middle, or lower lobe and the laterality of the biopsy (right vs. left vs. bilateral). The approach (character 5) may be one of the following:

• 0, Open: cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure (eg, open biopsy);

• 3, Percutaneous: entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure (eg, percutaneous needle biopsy);

• 4, Percutaneous endoscopic: entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure (eg, thoracoscopic needle biopsy);

• 7, Via natural or artificial opening: entry of instrumentation through a natural or artificial external opening to reach the site of the procedure; and

• 8, Via natural or artificial opening endoscopic: entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure (eg, bronchoscopy with biopsy of lung).

Therefore, a thoracoscopic wedge biopsy of the left upper lung lobe is classified to ICD-10-PCS code 0BBG4ZX.

According to the most current ICD-10-PCS Coding Guidelines (B3.4), if a biopsy is followed by a more definitive procedure at the same site, both the biopsy and the more definitive procedure are coded.

— Audrey Howard