Q&A Confused about 197.6

[Luna]

Watched the Webinar and saw this question was addressed.

How do you code malignant ascites primary site unknown. I have coded it as 197.1 for malignant ascites and 199.1 for the primary site unknown. My counter part wants to code it 789.59 and 199.1?

Webinar answer was: 197.6 199.1 789.51

I thought the peritoneum and the retroperitoneum was the inside layer and outside layer of the serous membrane lining the abdominal cavity. And so I thought that code 197.6 was saying your patient has secondary cancer of that membrane. I didn't see in the original question that cancer of the retroperitoneum or peritoneum was in the documentation. Since malignant ascites occurs in a variety of neoplasms, I didn't know it was OK to assume the patient in this scenario has cancer of the retroperitoneum/peritoneum.

So, according to the Webinar the coding should be: 197.6; 199.1; 789.51

• Patient has secondary cancer of the retroperitoneum/peritoneum (even though the documentation does not specify that cancer)
• Patient has/had primary cancer; site unknown
• Patient has malignant ascites (which is caused by a variety of malignancies, but documentation does not say which, and so we are going to say retroperitoneum/peritoneum)

I'm asking because I'm trying desperately to understand why we're using code 197.6. How and where does secondary cancer of the retroperitoneum/ peritoneum fit in with "patient has malignant ascites, primary site unknown."

Why is it not just 199.1 789.51

• Patient has/had primary/secondary cancer; site unknown
• Patient has malignant ascites

Why are we also adding cancer of the retroperitoneum/peritoneum?

 

[Carolyn Heath]

If you look up the code 789.51 Malignant Ascites, it has a code first note. The note says that you would code first malignancy and it gives two codes that you code first. The first code is malignant neoplasm of ovary 183.0 and second code is secondary malignant neoplasm of retroperitoneum and peritoneum 197.6. If you look at the problem, it says retroperitoneum/peritoneum, so the code for that would be 197.6. You would use 199.1 because you don't know what and where the primary cancer site was and you would still use the 789.51 for the ascites. If you put it in sequence, it would be 197.6, 199.1, 789.51.

 

[Luna]

I saw that note Carolyn and I thought the wording "such as" in it meant it was providing an example. So in this case how do we know whether the correct code was 183 or 197.6 when the note gives both of those codes? How do we know it was not lung cancer, breast cancer, colon cancer, and other cancers known to cause malignant ascites? In other words, is there a different malignant ascites code when it is caused by those other cancers? How would you code malignant ascites that is being caused by those other cancers if 789.51 is reserved only for ovarian and retroperitoneum/peritoneum cancers?

 

[Luna]

Carolyn, where in the problem does it say retropertitoneum/peritoneum? I thought it was just: How do you code malignant ascites primary site unknown. I have coded it as 197.1 for malignant ascites and 199.1 for the primary site unknown. My counter part wants to code it 789.59 and 199.1?

I'm so confused. Are we assuming the patient has a secondary cancer as well? It seems that we would only code the two things mentioned. The primary site unknown, and the malignant ascites. Thus 199.1 and 789.51

And that is what has me so stumped as a student. "Don't assume" and "code only what is documented" and yet it looks like we are assuming this patient must also have a secondary cancer if we are coding 197.6 just because a "such as" note said to. How do we know its OK to assume 197.6 or 197.6 instead of 183 if you can only code the two "such as" note?

 

[blondie8]

Carolyn, I'm going to post my answer on this subject that I created on another link. Keep in mind, I mostly code inpatient records, so of course in the OP setting, it might vary a little.

"One thing we have to be very careful about is allowing our research to supercede what the ICD-9 book points us towards for coding. Because there is a specific entry in the index for ascites, malignant, then we have to use that code, not immediately assume that it's caused by metastatic cancer of the peritoneum. I code inpatient records and have noticed that malignant ascites can be caused by many different cancers. While 197.6 and 183.0 are two of the more common causes, I've also seen it caused by kidney, liver, pancreas, and colon cancers, to name a few.

But the big thing to remember is this: Since most patients don't enter the acute care setting for treatment of ascites alone, (easy to do a quick paracentesis in the IRL suite,) there will almost always be a more acute and severe condition that is going to have to take the principal diagnosis slot. If the doctor gives us "malignant ascites," without immediately documenting a cause, then it's our clue to do some sleuthing in the record and track it down. And of course, you're absolutely right - if the doctors never specify, then it's time to write yet another query. (One of the hospitals that is a client of my company's is in the middle of a big CDI project, and I swear I write 10 queries per day!! )"

 

[Lori Woods]

It did say malignant ascites so that would mean neoplasm secondary to the unknown primary right?

 

[blondie8]

Malignant ascites is ascites caused by a malignancy. It is not itself necessary full of malignant cells.

 

[blondie8]

Ugh, and I can't type to save my life sometimes... It is not itself *necessarily* full of malignant cells. lol

 

[Lori Woods]

Malignant ascites: A condition in which fluid containing cancer cells collects within the abdomen. So this definition says to me neoplasm secondary to the unspecified primary neoplasm. I think that was part of what Alicia was trying to explain with her giant belly slide lol, & then we lost her.

 

[Carolyn Heath]

I am thinking that the "such as" relates to just the two codes. The Code First is the first part of an instructional note. You just pick the code that relates to the documentation. Here is the link to ICD9Data.com and it will lead you straight to the information about the code: http://www.icd9data.com/2013/Volume1/780-799/780-789/789/789.51.htm. There is a Code First with a question mark. Click on the question mark to read about the Code First.

 

[Carolyn Heath]

Thanks, Lori and Blondie8, for backing me up. I was doing some research on the "Code First Malignancy, such as" and found a link that may help explain things better: http://www.icd9data.com/2013/Volume1/780-799/780-789/789/789.51.htm.

 

[Luna]

It did say malignant ascites so that would mean neoplasm secondary to the unknown primary right?

Ascites is the accumulation of fluid in the abdomen. A variety of conditions like a non-cancerous tumor growth, or congestive heart failure, can create changes in gradient pressures in the abdomen, causing fluid to build up. That is ascites: a fluid build up not caused by cancer or containing cancerous cells..

Malignant ascites means that in the fluid, there were cancerous cells. Malignant ascites is not itself a cancer. It is only a condition caused by a cancer.

The body has many ways in which it tries to protect itself. When a person has cancer, one of the things the body tires to do to protect vital organ systems, is shed or drain the cancerous cells elsewhere. Sometimes, that means draining fluid into the peritoneal cavity. So, the cancerous fluid begins to build up in the abdomen. The fluid contains the shed or drained cancer cells. That is malignant ascites. Primary and Secondary cancers can be responsible for this condition. The fluid itself is not plagued by cancer. It merely contains cancerous cells that have been drained/shed there by a primary or secondary cancer/neoplasm somewhere in the body.

I think it may be a common misunderstanding that malignant ascites is synonymous with secondary neoplasm of the peritoneum.

 

[Luna]

I am thinking that the "such as" relates to just the two codes. The Code First is the first part of an instructional note. You just pick the code that relates to the documentation. Here is the link to ICD9Data.com and it will lead you straight to the information about the code: http://www.icd9data.com/2013/Volume1/780-799/780-789/789/789.51.htm. There is a Code First with a question mark. Click on the question mark to read about the Code First.

Thank you Carolyn. I do understand the "code first" note. It is necessary to code first the underlying disease first. That is why I agree with the 199.1 code and its sequence before 789.51.

What I'm failing to understand is why it is being suggested to also code 197.6. You are giving the patient a secondary neoplasm of the peritoneum (the membrane lining the abdomen) when that is not documented.

I'm thinking the "such as" is just providing examples and is not limiting you to the use of only the two "such as" codes.

So, if it were malignant ascites, lung cancer primary: you would code 162.9 789.51

If it were malignant ascites, ovarian neoplasm secondary, primary unknown, it would be 199.1 198.6 789.51

If it were malignant ascites, cancer of the peritoneum secondary, primary unknown, then it would be 199.1 197.6 789.51

If you find any other resources that can help me I'd appreciate it. I'm so frustrated right now, that I don't think I'll ever understand the coding notes and guidelines.

 

[blondie8]

The problem is the definition of ascites. This codes to the symptom category, not the neoplasm category, and there's a very important reason for that. Ascites = buildup of fluid in the abdomen. Malignant ascites = a malignancy is causing buildup of fluid in the abdomen - without cancer cells in it. Once cancer cells are found in the ascites, then that is malignant neoplasm of the peritoneum, whether primary or secondary. So here's an example:

Scenario 1: Doctor documents, "ovarian cancer and malignant ascites." Paracentesis is performed, cytology indicates no malignant cells. Final diagnosis documented on DS: "ovarian cancer with malignant ascites." I code: 183.0, 789.51.

Scenario 2: Doctor documents, "ovarian cancer and malignant ascites." Paracentesis is performed, cytology indicates metastatic carcinoma, consistent with ovarian origin. Doctor documents, "ovarian cancer with carcinomatosis" on the DS. I code: 183.0, 197.6, 789.51.

Scenario 3: Doctor documents, "ovarian cancer and malignant ascites." Paracentesis is performed, cytology indicates metastatic carcinoma, consistent with ovarian origin. Doctor documents, "ovarian cancer with malignant ascites." I code 183.0, and I send a query to the doctor to please clarify if s/he agrees with the pathology report's findings of metastatic cancer, waiting for a reply before I code the rest.

I hope this actually helps and doesn't make it worse!

 

[Luna]

The problem is the definition of ascites. This codes to the symptom category, not the neoplasm category, and there's a very important reason for that. Ascites = buildup of fluid in the abdomen. Malignant ascites = a malignancy is causing buildup of fluid in the abdomen - without cancer cells in it. Once cancer cells are found in the ascites, then that is malignant neoplasm of the peritoneum, whether primary or secondary. So here's an example:

Scenario 1: Doctor documents, "ovarian cancer and malignant ascites." Paracentesis is performed, cytology indicates no malignant cells. Final diagnosis documented on DS: "ovarian cancer with malignant ascites." I code: 183.0, 789.51.

Scenario 2: Doctor documents, "ovarian cancer and malignant ascites." Paracentesis is performed, cytology indicates metastatic carcinoma, consistent with ovarian origin. Doctor documents, "ovarian cancer with carcinomatosis" on the DS. I code: 183.0, 197.6, 789.51.

Scenario 3: Doctor documents, "ovarian cancer and malignant ascites." Paracentesis is performed, cytology indicates metastatic carcinoma, consistent with ovarian origin. Doctor documents, "ovarian cancer with malignant ascites." I code 183.0, and I send a query to the doctor to please clarify if s/he agrees with the pathology report's findings of metastatic cancer, waiting for a reply before I code the rest.

I hope this actually helps and doesn't make it worse!

Hi blondie8,

OK. So, maybe one of the flaws in my thinking is that malignancy related ascites (789.51) meant the paracentesis performed came back positive for cancer cells, confirming it is a cancer producing the fluid accumulation? Perhaps I was mistaken to think that that was why it was coded 789.51 versus 789.59. My thinking along with that though, was that a variety of cancers could be responsible for the presence of the cancer cells in the fluid, and so I thought 183 and 197.6 were provided as examples of malignancies to code.

But in actuality, malignant ascites (aka malignancy-related ascites) does not have to be positive for cancer cells in the fluid?
(I'm wondering how a doctor knows it is an ascites related to a malignancy and not something else like congestive heart failure then?)

So anyway, the doctor knows it is ascites related to a cancer, and not something else, and so he documents it as such and we'll code as xxx.x (for the malignancy documented whether ovarian, liver, colon, or other cancer the patient has) and 789.51? And if the malignancy is documented "unknown", we code it 199.1 with 789.51?

And then, when the fluid is positive for cancer cells, we code the xxx.x (malignancy documented), we then add 197.6 that the patient now has a neoplasm of the membrane lining their abdomen (because doctor documents that cancer cells were in the fluid), and 789.51 for the malignant ascites?

Do I understand it yet?

(Thank you guys for putting up with me bouncing my thoughts around in here. I don't know how else I'm going to learn without someone knowing what I'm thinking, and then correcting my reasoning. I have truly knowledgeable instructors here and value their input. I just think online learning is a greater challenge for students and instructors. But many have been successful this route and I hope I can become one of them.)

 

[blondie8]

Hi blondie8,

OK. So, maybe one of the flaws in my thinking is that malignancy related ascites (789.51) meant the paracentesis performed came back positive for cancer cells, confirming it is a cancer producing the fluid accumulation? Perhaps I was mistaken to think that that was why it was coded 789.51 versus 789.59. My thinking along with that though, was that a variety of cancers could be responsible for the presence of the cancer cells in the fluid, and so I thought 183 and 197.6 were provided as examples of malignancies to code.

But in actuality, malignant ascites (aka malignancy-related ascites) does not have to be positive for cancer cells in the fluid?
(I'm wondering how a doctor knows it is an ascites related to a malignancy and not something else like congestive heart failure then?)

Yes, bingo. That's why ICD has 789.59 - ascites without a cause documented, or caused by something other than cancer, and 789.51 - ascites known (or presumed) to be caused by cancer. The doctors don't always actually know for sure, but if they've ruled out other causes, or think it's "possible," then in the inpatient world, we code it as such.

So anyway, the doctor knows it is ascites related to a cancer, and not something else, and so he documents it as such and we'll code as xxx.x (for the malignancy documented whether ovarian, liver, colon, or other cancer the patient has) and 789.51? And if the malignancy is documented "unknown", we code it 199.1 with 789.51?

Yes, correct.

And then, when the fluid is positive for cancer cells, we code the xxx.x (malignancy documented), we then add 197.6 that the patient now has a neoplasm of the membrane lining their abdomen (because doctor documents that cancer cells were in the fluid), and 789.51 for the malignant ascites?

Depends on what you mean by "malignancy documented." The doctor actually has to state, "metastatic to peritoneum," or "carcinomatosis," or something synonymous with those terms. If s/he documents, "malignant cells were found on the cytology report," that's not enough to code the neoplasm. That would only code, I believe, to abnormal results on a cytology exam. I don't have my code books with me here at home, but I'm pretty sure that is in the symptom category too.

Do I understand it yet?

(Thank you guys for putting up with me bouncing my thoughts around in here. I don't know how else I'm going to learn without someone knowing what I'm thinking, and then correcting my reasoning. I have truly knowledgeable instructors here and value their input. I just think online learning is a greater challenge for students and instructors. But many have been successful this route and I hope I can become one of them.)

You're doing awesome. I too, went online for school, and there are a whole host of unique challenges that accompany that choice, aren't there? I am not a seasoned expert, but I have had the good luck and privilege to be trained one-on-one with arguably one of the best teachers in the state I'm in. (He's constantly having to turn down requests to train coders at facilities all over the state.) And he's pretty ruthless with auditing my coding down to the nit-picky-est thing, so I feel I've learned an incredible amount in a fairly short time.

If I get it wrong, hopefully someone with a swath of experience will come along behind me and set me straight!!!

 

[Luna]

Thank you blondie8. Your last statement helped me understand something that I didn't know if I understood or not. So, I'm thinking at this point, that I understand this particular question forward, and backward, and am not running into anymore, "what about this then?" type of hiccups. I'll stick with the 199.1 and 789.51. The 197.6 would only be added if the doctor documents cancer of peritoneum/retroperitoneum. Got it.

 

[Lori Woods]

Thanks Blondie & Luna that one was a killer huh lol. I agree Luna it is more difficult when you are learning online, but thanks to great people like Blondie who take the time to try to help us understand is invaluable & great of CCO to have this forum to do it in. I wonder why Alicia never chimed in though she must have gotten busy with settling in.

 

[Luna]

Thanks Blondie & Luna that one was a killer huh lol. I agree Luna it is more difficult when you are learning online, but thanks to great people like Blondie who take the time to try to help us understand is invaluable & great of CCO to have this forum to do it in. I wonder why Alicia never chimed in though she must have gotten busy with settling in.

Yes. I'm certain Alicia has a lot going on, plus it's the weekend and sometimes, you just need days off. And whether this was a misdirection in coding or not, I still have full confidence in her as an instructor and coder. She's excellent! Loves coding. Loves teaching. Loves sharing bonus material in the student forums. I'm glad to have her and CCO be a large part of my transformation into coding.

I also think the forums are great. Especially, when you are an online student. There is no one and no where else for me to go to sound out what's going on in the coding pocket of my brain. Being able to hash thoughts out with other students, coders, and instructors is so important to getting a good foundation in coding. It helps to make sure you understand the fundamentals.

I love my instructors. I love CCO. I love all the members here who help make this a great place stretch my coding IQ.

 

[Alicia Scott]

Aw, I found this post. Sorry it took me so long. Ruth pointed me in the right direction. THANKS Ruth.
So, I think I may be part of the confusion here everyone. When we get a question on the Q&A and are not sure what the direction of the question is we sort of go with what we know. I think that is what happened and I may have made an assumption.

This is how I took the question.
A patient comes in with 789.59 which is those Ascites that I pronounce funny.
The patient is dx with 197.6 that caused the ascites. However this was an assumption of mine. It just so happens that it is also the code given as an example in the manual. What we do know is that if a person is coded 789.59 we need to first code the CA that caused the 789.59 per the guideline.
In the question I thought that it was stated the primary CA was mentioned but not given. When this happens in documentation that means you can use 199.1. If however the primary CA is not mentioned the code 197.6 is enough. It is a code for a secondary CA. That is sufficient for the Payer in most cases.

So this really boils down in my eyes to where the question came from. If this was a test question I would say that you would use the 199.1. They would be testing to see if you knew it and that the 789.59 was sequenced after the CA code.

If this is a real world case question that changes it a bit. You could leave off the 199.1 because it would depend on what the payer wanted.

I think I didn't get the gist of what the real question was. I may have read into it a bit. Let me know if I am on track here or if there is more to the question then I am seeing. I LOVE these type of questions with ICD-9.

Sorry for the confusion. Again, I am sure this was on my part.