ICD-10-CM Coding Demonstration using Neoplasm Table
TLDRThe video script outlines the process of coding a medical scenario using ICD-10-CM, focusing on a 50-year-old female with a history of breast carcinoma and newly diagnosed brain metastases. It details the step-by-step approach to assigning diagnosis codes, emphasizing the use of the Neoplasm Table and the Alphabetic Index. The video instructs how to identify the primary diagnosis, code the metastatic cancer, and document the patient's history of mastectomy and chemotherapy, resulting in four key ICD-10 codes: C79.31, Z85.3, Z90.12, and Z92.21.
Takeaways
- π ICD-10-CM is used for coding medical diagnoses and procedures.
- π© The scenario involves a 50-year-old female with a history of breast carcinoma and new symptoms indicating metastatic brain cancer.
- 𧬠Metastatic cancer to the brain is coded using the Neoplasm Table in ICD-10-CM, found by looking up 'brain' in the table.
- π The code for secondary malignant neoplasm of the brain (not primary) is C79.31.
- π Verification of codes is done by referring to the tabular list in ICD-10-CM.
- π§ History of breast cancer is coded as Z85.3 in the tabular list under personal history.
- π©Ή A mastectomy is coded as an acquired absence of a body part, specifically Z90.12 for the left breast.
- π History of chemotherapy is coded as Z92.21 for personal history related to a neoplastic condition.
- π€ Understanding the alphabetical index is crucial for accurate ICD-10-CM coding.
- π» Encoders can assist with code lookup but require knowledge of correct terms to avoid errors.
- π The final set of codes for the scenario includes C79.31, Z85.3, Z90.12, and Z92.21.
Q & A
What is the purpose of using the Neoplasm Table in ICD-10-CM coding?
-The Neoplasm Table in ICD-10-CM is used to identify the specific codes for neoplasms, both primary and secondary, by listing all body parts in alphabetical order and providing the appropriate codes for malignant, benign, and uncertain neoplasms.
What was the patient's initial diagnosis and treatment?
-The patient was initially diagnosed with left breast carcinoma and underwent a left mastectomy along with chemotherapy administration.
What symptoms led to the patient's current visit?
-The patient presented with visual disturbances, dizziness, headaches, and blurred vision, which were later found to be due to metastases to the brain.
How was the metastatic cancer to the brain identified in the patient?
-The metastatic cancer to the brain was identified after work-up which revealed the presence of metastases, confirming that the symptoms were due to the spread of the previously treated breast cancer, not a new primary.
What is the ICD-10-CM code for secondary malignant neoplasm of the brain?
-The ICD-10-CM code for secondary malignant neoplasm of the brain is C79.31.
How is the history of breast cancer coded in ICD-10-CM?
-The history of breast cancer is coded as Z85.3, which represents a personal history of malignant neoplasm of the breast.
What is the ICD-10-CM code for a personal history of chemotherapy?
-The ICD-10-CM code for a personal history of chemotherapy for a neoplastic condition is Z92.21.
How is the absence of a body part, specifically the breast, coded in ICD-10-CM?
-The absence of the breast is coded as Z90.1, with an additional character needed to specify the side, such as Z90.12 for the left breast.
Why is it important to verify the codes in the tabular list of ICD-10-CM?
-Verification in the tabular list ensures the accuracy of the codes, confirming that they correctly represent the diagnosis or condition, and helps identify if any additional characters or notes are required for a complete code.
What are the four ICD-10-CM codes assigned to the patient in the given scenario?
-The four ICD-10-CM codes assigned are: C79.31 for secondary malignant neoplasm of the brain, Z85.3 for personal history of malignant neoplasm of the breast, Z90.12 for acquired absence of the left breast and nipple, and Z92.21 for personal history of antineoplastic chemotherapy.
How does the process of coding with ICD-10-CM help in understanding a patient's medical history and current condition?
-ICD-10-CM coding provides a systematic and standardized way of documenting a patient's medical history, including past diagnoses, treatments, and current conditions. This facilitates accurate communication among healthcare providers, aids in tracking the progression of diseases, and is essential for billing and statistical analysis.
Outlines
π Introduction to ICD-10-CM Coding for Metastatic Cancer Scenario
This paragraph introduces a coding scenario using ICD-10-CM, focusing on the use of the Neoplasm Table. It presents a case of a 50-year-old female with a history of left breast carcinoma, who now presents with symptoms of visual disturbances, dizziness, and headaches due to brain metastases. The speaker explains the process of assigning diagnosis codes, starting with the identification of the metastatic cancer to the brain and coding the history of breast cancer. The speaker emphasizes the importance of understanding the ICD-10-CM coding system and the correct use of the alphabetic index and tabular list.
π©Ί Coding for Mastectomy and Chemotherapy History
In this paragraph, the speaker continues the coding process by addressing the patient's history of mastectomy and chemotherapy. The speaker explains how to look up and code the absence of a body part, specifically the breast, and how to code the history of chemotherapy for a neoplastic condition. The speaker provides the final codes for the scenario: C79.31 as the principal diagnosis for metastatic cancer to the brain, Z85.3 for personal history of malignant neoplasm of the breast, Z90.12 for the acquired absence of the left breast and nipple, and Z92.21 for personal history of antineoplastic chemotherapy. The speaker also highlights the importance of verifying codes in the tabular list to ensure accuracy.
Mindmap
Keywords
π‘ICD-10-CM
π‘Neoplasm Table
π‘Metastatic Cancer
π‘Mastectomy
π‘Chemotherapy
π‘Personal History
π‘Principal Diagnosis
π‘Alphabetic Index
π‘Tabular List
π‘Coder
π‘Encoder
Highlights
Coding a scenario using ICD-10-CM for a 50-year-old female with a history of breast carcinoma and new symptoms.
The patient had a left mastectomy and chemotherapy four years prior, with no further treatment except yearly check-ups.
Presenting symptoms include visual disturbances, dizziness, headaches, and blurred vision.
Work-up reveals metastases to the brain, identified as metastatic from the breast, not a new primary.
The primary breast cancer is coded as a history of breast cancer, using the Neoplasm Table.
Metastatic cancer to the brain is coded using the malignant secondary column in the Neoplasm Table.
The code for secondary malignant neoplasm of the brain (brain NEC) is C79.31.
The patient's history of breast cancer is coded as Z85.3 in the tabular list.
The mastectomy is coded as an acquired absence of breast and nipple, specifically for the left breast, as Z90.12.
The personal history of chemotherapy for the neoplasm is coded as Z92.21.
The importance of using the correct terms in the alphabetical index when looking up codes to avoid incorrectηΌη by an encoder.
The process of verifying codes in the tabular list to ensure accuracy and completeness.
The final set of four codes for the scenario: C79.31, Z85.3, Z90.12, Z92.21.
The significance of distinguishing between primary and metastatic cancers for accurate coding.
The necessity of coding the patient's personal history of chemotherapy as part of the medical record.
The detailed explanation of the ICD-10-CM coding process, providing a clear guide for users unfamiliar with the system.
The emphasis on the importance of understanding the structure of ICD-10-CM codes and the use of subheadings.
The practical application of ICD-10-CM coding in a clinical scenario, demonstrating its relevance to healthcare documentation.
Transcripts
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