Q&A: Coding and sequencing clarification
Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially, the physician documented possible pulmonary nodular amyloidosis (PNA) but following an echo-cardiogram on day one they found a pericardial effusion (malignant). The initial report says no tamponade. The next day the patient had a cardiac arrest. Given the pericardial effusion, staff performed a bedside echo during resuscitation. This showed right atrial collapse and the physician performed an emergent pericardiocentesis for pericardial tamponade. The patient was resuscitated but deemed terminal and later died. No definitive treatment was directed at the lung cancer.
We are discussing two concerns related to this case:
- How to code the effusion: Our coder thinks it may be appropriate to only code C7989 (secondary malignant neoplasm) but I think that I39.3 (pleural effusion) should be coded.
- Sequencing: Our coder assigned C7989 as the principal diagnosis. If we code I39.3, would that end up being the principal? The Official Guidelines for Coding and Reporting say that complications of neoplasm should be listed as principal.
Any suggestions or thoughts you might have would be greatly appreciated.
A: J91.0 (Malignant pleural effusion) is a manifestation code and cannot be sequenced as the principal diagnosis, says Sharon Salinas, CCS, HIM manager, at Barlow Respiratory Hospital in Los Angeles. “The underlying condition is to be sequenced first. Per the National Institutes of Health, malignant pericardial effusion is also a manifestation so I think the lung neoplasm might have to be the principal if that is the underlying cause.”
Look also at ICD-10-CM code I30.9 for acute neoplastic pericardial effusion present on admission (POA) plus the C code for secondary malignancy POA and finally, pericardial tamponade, not POA, suggests Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
AHA Coding Clinic for ICD-9-CM, Second Quarter 1989, directs coders to the Alphabetic Index entry for effusion, pericardium, which has a note to “see also pericarditis,” and leads to options of pericarditis (with effusion), neoplastic (chronic), and acute, he says.
“The physician should be asked if, in this particular instance, the pericarditis is acute or chronic in nature. One of the causes of noninfectious pericarditis with effusion is a tumor, either a primary tumor (benign or malignant) of the pericardial site, or a tumor metastasizing to the pericardium (commonly carcinoma of the lung or breast and lymphomas),” said Gold.
Unfortunately, says Salinas, ICD-10-CM lost some specificity for situations like this. Code I313, for pericardial effusion isn’t specifically for malignant pericardial effusion but comes close. Code J91.0, is a manifestation code and cannot be sequenced as principal diagnosis.
“I would query for acuity and for underlying cause of effusion (primary, metastatic, other, undetermined. I think you need both queries to determine the principal,” she said.
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