ICD-10 coding challenge: Removal of lymph node tissue

Julia Palmer, project manager with the consulting services business of 3M Health Information Systems, is author of this month’s coding challenge blog.

CHALLENGE QUESTION

Patient had a melanoma of the abdomen excised on a previous admission and is admitted now for superficial groin dissection of sentinel lymph node. According to the operative note: "This is a very pleasant 42-year-old female who, unfortunately, was found to have an intermediate thickness melanoma with a Breslow depth of 2.7 mm located on her abdomen in the left lower quadrant. She underwent a sentinel lymph node biopsy and wide local excision of the previous tumor and unfortunately, the pathology showed positive 4.3 cm lymph node with extracapsular extension. Of note, her sentinel lymph node localized to the left lower groin. Given these findings, she was readmitted for superficial inguinal lymph node removal of the left groin."

The physician also noted in the op note: “We continued with our dissection more inferiorly and connected the specimen between the two incisions at a level above the inguinal ligament and proceeded to remove all nodal tissue en bloc. At that point, we oriented the specimen and sent it for final pathology review.”

Assign only the ICD-10 diagnosis code for the reason for the surgery and the ICD-10-PCS code for the removal of the lymph node tissue.

ANSWER

C774                     Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes

07TJ0ZZ               Resection of left inguinal lymphatic, Open Approach

During this encounter, treatment was directed at the secondary malignant site of the left inguinal lymph node, so C774 should be sequenced as the principal or first listed diagnosis, i.e., the reason for the surgery. We don’t know the status of the melanoma of the abdomen, other than it has been excised. Treatment of the abdominal site may or may not be ongoing; however, it was not the focus of this encounter. Coding guidelines state: When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

For the procedure, the correct root operation is resection since the physician documented in the op note “proceeded to remove all nodal tissue en bloc.” One participant in this coding challenge asked if a second procedure code, specifically the code for excision with qualifier of diagnostic, is needed to identify the fact that the lymph node tissue was sent for pathology review. Actually, no. No additional code is needed. Tissue is routinely sent to pathology for review but more importantly, the purpose of the procedure was to remove the tissue because diagnosis was already established and the procedure was treatment for that diagnosis. A diagnostic excision code would have been appropriate on the previous encounter when the sentinel lymph node biopsy was performed.

Thanks to all who participated. We hope to see you next time!

Julia Palmer is a project manager with the consulting services business of 3M Health Information Systems.