This article discusses about the coding of metastatic cancer and the alternate terms used in the medical record by the physicians. In my experience, I have seen many coders struggling to assign the appropriate codes for primary and secondary cancers. This is due to the fact they lack knowledge in the terminologies resulting in improper code assignment.
When you are clear about the terminologies and the definitions and the differences between the terms, it would be easier for you to pick up the correct codes without any confusion.
So let’s take a bit of a deeper dive into the subject.
What is a cancer?
Cancer is a term for diseases in which abnormal cells divide without control and can invade nearby tissues. The main reason that cancer is so serious is its ability to spread in the body. The process by which cancer cells spread to other parts of the body is called “metastasis” and the plural form of metastasis is the “metastases”.
What is an advanced cancer?
Generally the term “advanced cancer” is used to refer cancers that cannot be cured. There are two types of advanced cancers described as below:
Locally advanced cancer: This cancer is used to describe cancer that has grown outside the organ it started in but not yet spread to distant parts of the body.
Metastatic cancer: It is a cancer that has spread to distant parts of the body.
What is a metastatic cancer?
Metastatic cancer is a cancer that has spread from the part of the body where it started (the primary site) to other parts of the body. Cancer cells can spread either locally, regionally or to the distant sites based on the severity of the disease.
Locally: by moving into nearby normal tissues
Regionally: to nearby lymphnodes, tissues or organs.
Distant sites: spread to distant parts of the body. (Metastatic cancer)
Most common terms used to represent cancer by the physicians:
Physicians may use different terms such as the primary site, secondary site, metastatic cancer, and others in the medical record. Therefore the coders need to review the medical record carefully and assign the appropriate codes.
Primary site: The site where cancer originates is known as the primary site. A neoplasm is always described in terms of the primary site, even if it has spread or metastasized to another part of the body. For example, breast cancer that has metastasized to the lungs is always described as breast cancer and not the lung cancer.
Secondary site: When cancer cells spread to other parts of the body, these are referred to as secondary sites or metastases.
Metastatic from: This indicates a primary cancer, the original site of the cancer.
Example: Metastatic carcinoma from the breast indicates that the breast is the primary site of the cancer.
Metastatic to: A new site of cancer that has growth from the original site.
Example: Metastatic carcinoma to the lung indicates that the site mentioned is secondary and therefore coded as secondary malignant neoplasm of the lung.
Assign the diagnosis of a 72-year old female patient presented with small cell carcinoma of the right lower lobe of the lung with metastasis to the intrathoracic lymph nodes and brain.
Primary site: small cell carcinoma of the right lower lobe of the lung
Secondary site: intrathoracic lymph nodes and brain.
Codes: C34.31, C77.1, C79.31
Assign the diagnosis of a patient presented with carcinoma of the central portion of the right breast, metastatic to the liver and brain.
Primary site: carcinoma of the central portion of the right breast.
Secondary site: liver and brain.
Codes: C50.111, C78.7, C79.31
Happy learning! Happy coding!