Breast Cancer Awareness Month!

Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor

Breast cancer is a disease that affects both women and men.  Although rare in men, the CDC states that 1 out of every 100 breast cancer diagnoses is found in men.  We raise awareness about breast cancer, promote early detection, and support those affected by this disease. We continue to help individuals and families impacted by breast cancer, all those who fought and may have lost the battle, those still fighting, and those caregivers selflessly giving their all to help their loved ones make it. The most reliable predictor of the success, early prevention and treatment of breast cancer is screening mammography, which lowers the risk by 19%, states The Journal of Nuclear Medicine.  It is a direct reduction of advanced-stage breast cancer metastasis and an increase in life expectancy among women participating in annual screening mammography. Therefore, the ultimate goal is to decrease the death rate from breast cancer. 

Diagnosis specificity is crucial when coding breast cancer for several reasons, primarily related to accurate patient care, medical research, coding and billing. Physicians rely on precise coding to make informed decisions about surgery, chemotherapy, radiation therapy, and other treatments. Specific codes guide them in selecting the most effective interventions. Incorrect diagnosis codes can affect patient care as well as reimbursement.

Accurate and specific coding ensures a patient’s medical records contain complete, detailed information. This information is vital for continuity of care, particularly when patients change healthcare providers or locations.

Prognosis

The prognosis for breast cancer can vary widely based on factors like the stage and subtype of cancer. Specific coding provides critical information for estimating the patient’s prognosis and expected outcomes.

Documenting and Coding

Those who have attended different educational sessions I have conducted over the years know I speak on the importance of diagnosis specificity.  It is a topic I can’t stress enough.  When auditing a record, we often see unspecified diagnosis codes.  After analyzing the documentation, we know that documentation supports more specified diagnoses or combination codes.  Then, we have the records where maybe a more specified code was used, but the documentation did not support it. 

Specificity and clinical documentation are critical for general documentation & coding.  Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record Per ICD-10-CM Guidelines.  Coding and auditing professionals must be able to determine if a condition is current and active or a history.  ICD-10 CM guidelines should be reviewed when reporting codes.  It is also essential to ensure that coders review the appropriate coding guidelines for the date of service and year they are reviewing.

Educating providers on the importance of their documentation regarding proper code assignment is essential. But it is also vital for coders to understand the O’clock positions/quadrants and codes of the breast. Unspecified Diagnosis codes should only be reported if documentation does not support specificity.

When providers document and diagnose breast cancer, documentation must be clear, up-to-date and accurate. This allows the diagnosis code to be coded to the highest level of specificity and not just “unspecified”. Some terminology to look out for are:

  • Malignancy (primary vs secondary)
  • Ca in situ
  • Benign
  • Uncertain Behavior
  • Unspecified Behavior
  • Signs and symptoms vs confirmed diagnosis
  • Overlapping sites
  • History of vs Active Treatment
  • On Hormonal Therapy
  • Prior excision or eradication

Coders should query a provider for clarification if documentation is not clear. Providers and coders should also keep abreast of guidelines and new diagnosis changes effective every October 1 to ensure correct coding.

Laterality

Per ICD-10-CM, some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left-right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right sides. If the side is not identified in the medical record, assign the code for the unspecified side. If there is conflicting medical record documentation regarding the affected side, the patient’s provider should be queried for clarification. Codes for the “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side, and it is impossible to obtain clarification.

• Nipple C50.0xx

• Central portion of breast C50.1xx

• Upper inner quadrant of breast C50.2xx

• Lower inner quadrant of breast C50.3xx

• Upper outer quadrant of breast C50.4xx

• Lower outer quadrant of breast C50.5xx

• Axillary tail of breast C50.6xx

• Overlapping lesion of breast C50.8xx

• Breast NOS C50.9xx

In summary, specificity in breast cancer coding is essential for providing individualized patient care, supporting medical research, enabling proper billing and reimbursement, and contributing to healthcare quality and epidemiological data. It ensures that breast cancer cases are accurately documented, improving patient outcomes and advancing breast cancer treatment and prevention.

To schedule training for your organization or private practice providers’ clinical and billing staff, email us today at info@kwadvancedconsulting.com or visit the website and fill out the “contact us” form.

Resources

https://jnm.snmjournals.org/content/57/Supplement_1/9S

https://www.cancer.gov/types/breast/hp/breast-screening-pdq

https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines.pdf

https://seer.cancer.gov/archive/manuals/2012/AppendixC/breast/coding_guidelines.pdf

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