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December 6, 2010

Coding for Lymphoma
For The Record
Vol. 22 No. 22 P. 27

Lymphoma is a type of blood cancer originating in the lymphatic system and occurs when the cells behave abnormally.

Lymphomas are classified to ICD-9-CM categories 200 to 202. The specific code assignment depends on the cell type as documented by the physician. A fifth-digit subclassification is required to identify the site of the organ or lymph node involved as follows:

• 0: unspecified site, extranodal and solid organ sites;

• 1: lymph nodes of head, face, and neck;

• 2: intrathoracic lymph nodes;

• 3: intra-abdominal lymph nodes;

• 4: lymph nodes of axilla and upper limb;

• 5: lymph nodes of inguinal region and lower limb;

• 6: intrapelvic lymph nodes;

• 7: spleen; and

• 8: lymph nodes of multiple sites.

Many fifth-digit subclassifications pertain to lymph node sites. If the lymphoma affects lymph nodes in more than one region of the body, assign the fifth digit of 8. If the lymphoma is located in an extranodal site or solid organ (eg, brain), then the fifth digit 0 will be assigned.

Although the lymphoma may be described as spreading beyond the lymphatic system, the code assignment should remain within the 200 to 202 category codes. “Lymphomas are systemic diseases that do not ‘metastasize’ in the same way that solid tumors do. … A lymphoma, regardless of the number of sites involved, is not considered metastatic, and should be coded to the 200-202 categories” (AHA Coding Clinic for ICD-9-CM, 1992, second quarter, page 3).

It is common for solid tumors (classified to categories 140 to 199) to metastasize to lymph nodes. This is not considered a lymphoma and would not be classified to categories 200 to 202. Instead, it would be assigned to a code from category 196.

Documentation of lymphoma in remission is still assigned to the appropriate code from categories 200 to 202. “Lymphoma patients who are in remission are still considered to have lymphoma and should be assigned the appropriate code from categories 200-202” (AHA Coding Clinic for ICD-9-CM, 1992, second quarter, page 3). If the disease is completely cured and documented as “history of,” assign code V10.79 as a secondary diagnosis.

Lymphomas are divided into two main categories: Hodgkin’s and non-Hodgkin’s lymphoma. Hodgkin lymphoma is an uncommon form that involves Reed-Sternberg cells, or typically abnormal B cells that originate in the bone marrow, won’t die, and continue producing more abnormal B cells. The following are the common classifications of Hodgkin’s lymphoma:

• Hodgkin’s paragranuloma (201.0);

• Hodgkin’s granuloma (201.1);

• Hodgkin’s sarcoma (201.2);

• Lymphocytic-histiocytic predominance (201.4);

• Hodgkin’s lymphoma, nodular sclerosis (201.5);

• Hodgkin’s lymphoma, mixed cellularity (201.6);

• Hodgkin’s lymphoma, lymphocytic depletion (201.7); and

• Hodgkin’s lymphoma, malignant lymphogranuloma, or lymphogranulomatosis (201.9)

Non-Hodgkin’s lymphomas are tumors that develop from an overabundance of lymphocytes and do not involve Reed-Sternberg cells. The following are the common ICD-9-CM classifications of non-Hodgkin lymphoma:

• Reticulosarcoma (200.0);

• Lymphosarcoma (200.1);

• Burkitt’s tumor or lymphoma (200.2);

• Marginal zone lymphoma (200.3);

• Mantle cell lymphoma (200.4);

• Primary central nervous system lymphoma (200.5);

• Anaplastic large cell lymphoma (200.6);

• Large cell lymphoma (200.7);

• Nodular lymphoma (202.0);

• Mycosis fungoides (202.1);

• Sézary’s disease (202.2); and

• Peripheral T-cell lymphoma (202.7).

The most common signs and symptoms associated with lymphoma include swelling of the lymph nodes in the neck, armpit, or groin; fever; unexplained weight loss; night sweats; chills; fatigue; itching; and abdominal pain/swelling.

To diagnose lymphoma, a physician may conduct a physical examination of the lymph nodes to check for swelling or lumps, take blood or urine samples to rule out other infections that may cause lymph node swelling, order a CT scan to determine the presence of tumors, order an MRI, order a lymph node biopsy to identify the cell type and the presence of the Reed-Sternberg cell, or order a bone marrow biopsy.

Treatment depends on the type of lymphoma, stage of the disease, and the speed of growth. Treatment may involve one or a combination of the following: chemotherapy, radiation or biologic therapy, radioimmunotherapy, or stem cell or bone marrow transplantation.

Coding and sequencing for lymphoma 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.