Neoplasm ICD 10 codes have to be used very carefully. Cancer conditions can be partially or fully present or removed from the body, hence the ICD 10 codes will also vary as per the scenario. For example, the personal history code for neoplasm should be used only when the neoplasm has been completely removed from the body. Similar follow-up visit code for neoplasm needs to reported only when the cancer has been removed totally from the body.
For coding neoplasm diagnosis codes you will come across two medical terms: remission and relapse. Medical coders should understand the meaning of these two terms for correct coding of neoplasm codes.
Read also: Primary and Secondary ICD 10 Z codes used for Neoplasm Chapter
What do you mean by Remission?
As per the definition of National Cancer Institute the remission is defined as ” a decrease in or disappearance of signs and symptoms of Cancer“. There can be partial or complete remission. In Partial remission some, but not all, of the signs and symptoms of cancer disappear. In complete remission, all the signs and symptoms of cancer disappear, although the cancer may be present in the body. During periods of remission, no symptoms of the disease are noticeable.
Now, here the use of personal history of neoplasm ICD 10 Z codes should be used carefully. When the documentation in the report completely supports the occurrence of remission, then only the personal history code for malignancy should be used. When the documentation is not clear about the remission, do query the provider before assigning the personal history ICD 10 Z codes.
Do remember while coding personal history of neoplasm, the patient is not receiving any medication for neoplasm. If the patient is going through a radiotherapy or chemotherapy for neoplasm, the history of neoplasm codes should not be assigned, active neoplasm ICD 10 code should be reported as per ICD 10 coding guidelines.
Read also: Sample Medical coding Examples for Medical coders
What is Relapse?
A relapse is when cancer returns after a disease-free period. The remission of malignancy may be followed by relapse. In relapse, the signs and symptom can reoccur for malignancy. In such scenarios, the ICD 10 codes for personal history for malignancy should be used only when there is no evidence of malignancy.
There are separate ICD 10 codes for remission and relapse for conditions like multiple myeloma & leukemia.
Leukemia, also spelled leukaemia, is a group of cancers that usually begin in the bone marrow and result in high numbers of abnormal white blood cells. These white blood cells are not fully developed and are called blasts or leukemia cells. It is usually accompanied by anemia, impaired blood clotting, and enlargement of the lymph nodes, liver, and spleen.
Multiple myeloma is a cancer formed by malignant plasma cells. Normal plasma cells are found in the bone marrow and are an important part of the immune system. The immune system is made up of several types of cells that work together to fight infections and other diseases.Multiple myeloma, monoclonal gammopathy of undetermined significance (MGUS), and plasmacytoma are types of plasma cell tumors.
- C90.0 – Multiple myeloma
- C90.00 – Multiple myeloma not having achieved remission
- C90.01 – Multiple myeloma in remission
- C90.02 – Multiple myeloma in relapse
- C90.1 – Plasma cell leukemia
- C90.10 – Plasma cell leukemia not having achieved remission
- C90.11 – Plasma cell leukemia in remission
- C90.12 – Plasma cell leukemia in relapse
- C90.2 – Extramedullary plasmacytoma
- C90.20 – Extramedullary plasmacytoma not having achieved remission
- C90.21 – Extramedullary plasmacytoma in remission
- C90.22 – Extramedullary plasmacytoma in relapse
- C90.3 – Solitary plasmacytoma
- C90.30 – Solitary plasmacytoma not having achieved remission
- C90.31 – Solitary plasmacytoma in remission
- C90.32 – Solitary plasmacytoma in relapse
As noted previously, in a complete remission, all signs and symptoms of cancer have disappeared. Some doctors may say a patient is cured after 5 years or more of being in complete remission. Consider these facts and the doctor’s documentation when assigning a history code.