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September 14, 2009

Coding for Melanoma
For The Record
Vol. 21 No. 17 P. 28

Making the correct code selection often centers around knowing the tumor site.

Melanoma is a malignancy of the melanocytes. Although it accounts for only a small percentage of skin cancer, it causes the greatest number of deaths compared with other types of cancer. Patients with excessive exposure to UV radiation are at an increased risk for developing melanoma. Other common risk factors include fair skin, a history of sunburn, high-altitude climates, a family history of melanoma, and a weakened immune system.

Melanoma can occur anywhere on the body but is found most often in areas that have the greatest sun exposure, such as the back, legs, arms, and face. However, it can also develop in an area of little sun exposure and is termed “hidden melanoma.”

Malignant melanoma is classified to ICD-9-CM category 172. A fourth-digit subcategory is necessary to identify the tumor site. Malignant melanoma affects deeper layers of the skin and has a greater potential for metastasis.

Other types of skin cancer include the following:

• Basal cell carcinoma, which accounts for a majority of all skin cancers, is classified to category 173. Once again, a fourth-digit subcategory is needed to identify the specific tumor site. It originates in the lowest layer of the epidermis. The tumors are typically superficial and slow growing, occurring mainly on the face, neck, and ears, and rarely metastasize.

• Squamous cell carcinoma, which originates in the middle layer of the epidermis, is also classified to category 173. The tumors are typically superficial and slow growing, mainly occurring on the face, hands, and ears.

• Kaposi’s sarcoma of the skin (176.0) is a rare form of skin cancer that results in red or purple patches on the skin or on mucous membranes. It is seen mainly in patients with weakened immune systems (eg, those with AIDS).

• A Merkel cell tumor (category 173) is a neuroendocrine tumor of the skin that typically appears on the face or scalp. It is fast growing and usually spreads before detection (AHA Coding Clinic for ICD-9-CM, 2000, first quarter, page 18).

• Sebaceous gland carcinoma (category 173) originates in the skin’s oil glands and appears as hard, painless nodules, most commonly on the eyelid.

There is an “excludes” note under categories 172 and 173 that states if the skin cancer involves genital organs, it should be assigned a code from range 184.0 to 184.9 or 187.1 to 187.9. In addition, an excludes note under category 172 states if the malignant melanoma is of a site other than the skin to code to malignant neoplasm of the site.

The first symptoms of melanoma include a change in an existing mole and the development of a new, unusual-looking growth on the skin. Moles that may indicate melanoma or other types of skin cancer follow the A-B-C-D-E guide, which stands for the following:

• Asymmetry: irregular shape with two very different looking halves;

• Border irregularity: ragged, notched, or blurred edges;

• Changes in color: many colors, uneven color distribution;

• Diameter: larger than 1⁄4 inch (6 mm) in a new mole; and

• Evolving: changes over time; grows in size or changes color or shape.

Other symptoms include scaling, itching, change in texture (eg, becomes hard or lumpy), spreading of pigment from mole to surrounding skin, and oozing or bleeding.

A diagnosis of melanoma is confirmed by a skin biopsy. A portion of the tumor or the entire tumor is removed and submitted for evaluation. The lesion is removed by a knife or punch biopsy. A skin biopsy of most sites is classified to code 86.11. Note that skin biopsies of some sites are excluded from code 86.11. Therefore, the coder should refer to the alphabetic index for specific code assignment.

The treatment for melanoma depends on the severity, the patient’s overall health, and other personal preferences. Surgical excision of the cancerous tissue and a margin of healthy skin to ensure complete removal is the most common treatment plan. If the skin cancer has metastasized, treatment could include removal of the affected site, such as lymph node excision. Chemotherapy, radiation therapy, and immunotherapy may also be used to treat malignant melanoma.

Coding and sequencing for melanoma 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 4,000 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.