Can one choose a cancer diagnosis code without tissue?

Jonathan Rubenstein, MD

My provider performed a laparoscopic radical nephrectomy (90-day global procedure) on a patient with a renal mass worrisome for kidney cancer. I was told not to use a “kidney cancer” diagnosis until cancer was proven, so I used a “renal mass” ICD-10 code. The final pathology report confirmed kidney cancer. My provider wants to bill for the post-op visits within 90 days saying billable because the patient now has a diagnosis of cancer that they did not have before the surgery. Can we bill those visits?

The short answer is no. But it may be best to explain why Let’s start with the diagnosis code portion. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10 CM) guidelines instruct the clinician to choose a diagnosis code that accurately describes a patient’s clinical condition or reason for visit. Additionally, the guidelines instruct the coder supporting the clinician to check the appropriate code selection with the clinician when there is a question. In short, the clinician has the final say regarding which ICD-10-CM code should be used.

Mark Painter

It is likely there are clinicians who would argue that based upon imaging alone, they are comfortable making a diagnosis of cancer without a biopsy or tissue diagnosis, especially with more modern imaging. However, we believe that it remains best practice to only use a cancer diagnosis code in patients with pathologic tissue confirmation with rare exceptions (such as with cancer recurrence or metastasis and those who need treatment and tissue cannot be obtained). In addition to the medical implications of a cancer diagnosis, many such diagnoses will affect patient insurability and potential employment. From a coding perspective, diagnoses assigned prior to confirmation may result in the bundling of care that should be separately payable. That being said, at times a clinician needs to use their best clinical judgment when caring for an individual patient, as some patients may not be eligible for certain therapies without the corresponding diagnosis codes being chosen. However, in the case of the renal mass mentioned above, most providers will use a “renal mass” diagnosis code instead of a “kidney cancer” code.

Now, let’s get to the question about whether visits within 90 days after laparoscopic radical nephrectomy are billable if a patient now has a definitive diagnosis of kidney cancer. The global surgical package is set up in a way such that payment has already been made to include all the necessary services normally furnished by a surgeon before, during, and after a procedure. That means that all hospital and outpatient visit that occur within that global period have been paid, unless an exception exists. According to Medicare, services such as evaluation and management (E/M) visits that are not included in the global payment package and are separately payable within a global period include:

1. Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

2. Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.

In this particular case, the intent of the surgery was for the treatment of a known or suspected kidney cancer, whether or not a kidney cancer diagnoses code was used or was confirmed before the procedure. Had the physician not suspected that the patient had cancer, the patient would likely not have undergone the nephrectomy. A computer may require and allow for an E/M code to be reported with a different diagnosis than used for the surgery and modifier –24 (Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period), which states that the “physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.” However, the definition of the modifier is not specific to the diagnosis code but instead focuses on “reason(s) unrelated to the original procedure,” nor is the Medicare rule limited to a specific diagnosis—“visits unrelated to the diagnosis for which the original surgical procedure is performed.”

Therefore, billing for the visits based solely on a change in diagnostic code is not appropriate, as noted in point 1 above.The visits are clearly related to the reason(s) for which the surgical service was performed, regardless of the ICD-10-CM code reported for the surgical service. On the other hand, the second point above would warrant additional consideration.

Chemotherapy care provided for the systemic treatment of cancer is not related to the recovery from surgery. Instead, it is targeted to treatment of the underlying disease and is an added course of treatment not considered a part of normal recovery from surgery. Under this exception, the services related to the treatment for kidney cancer are payable.

The visits for planning and follow-up during the global period are not as clear cut. In reviewing multiple charts, it is common for a physician to discuss with the patient, prior to laparoscopic radical nephrectomy, the potential for kidney cancer and the need for further treatment after surgery, including chemotherapy. As this discussion is common for surgery, it is harder to support the position that this planning is not a normal part of the recovery from surgery. If there is no suspicion of cancer and the laparoscopic partial nephrectomy is performed with a discovery of cancer during or after surgery, the argument that the cancer treatment planning and follow-up for cancer is not a part of normal recovery is supported. Even with that differentiation, we have to remember that relative value units and rules are developed not for the individual case but instead for the average case.

In summary, charging for visits during the postoperative period for planning and follow-up of cancer will depend on documentation and payer processing. In general, similar to the discussion of stone prevention during the postoperative period of an extracorporeal shock wave lithotripsy, payment may be warranted in some cases but may be difficult to obtain.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.