This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of pathology. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.
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Preparing for ICD-10-CM: Neoplasm Breast Carcinoma in-situ
The following example discusses the documentation required to support the ICD-10-CM code for neoplasm breast carcinoma in-situ.
Clinical History: Abnormal left mammogram
Gross Description: The specimen is received in formalin labeled with the patient’s name and as “left breast calcifications stereotactic biopsy”. There are multiple cylindrical pieces of yellow and white soft tissue, each of which measure 0.1 cm in diameter. The pieces range in length from 0.3 to 3.2 cm in length. Totally submitted in block 1A.
Final Diagnosis: Left breast calcifications, stereotactic core needle biopsy: ductal carcinoma in-situ, comedo type with necrosis and microcalcifications, high grade.
ER and PR both positive.
What diagnosis codes are assigned?
Documentation is always the key. ICD-10-CM has added the component of laterality, meaning some codes will indicate whether the condition occurs on the left, right or bilateral. If not, then assign separate codes for both the right and left side where applicable. There is also a code for unspecified side although it would be beneficial to be as specific whenever possible.
The above scenario is possibly lacking key documentation to assign ICD-10-CM to the highest level of specificity. ICD-10-CM has specific codes for “intraductal” carcinoma in situ D05.10-D05-12; the documentation must state “intraductal” to support assigning the code selection. This report only has ductal and the coder cannot assume it means intraductal. ICD-10-CM has also included a specific code section for “lobular” carcinoma in situ D05.00-D05.02; again the documentation must clearly state “lobular” before selecting this code group. There are also “other” and “unspecified” code selections in this code group. As you can see breast carcinoma in-situ went from one ICD-9 code to twelve potential ICD-10-CM codes. It is very important to make note that documentation must be clear and precise in order to assign the highest level of specificity for ICD-10.
Draft 2013 ICD-10-CM, Complete Draft Code Set
Kimberly J. West, CPC