ICD-10 CM/PCS Tip Sheets. Oncology
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1 ICD-10 CM/PCS Tip Sheets Oncology
2 About This Guide This collection of tip sheets has been developed by Cape Fear Valley Health to promote greater specificity of the coded data for a given condition, disease, diagnosis, and/or surgical procedure. It has been reformatted by the Dignity Health ICD-10 program to provide a handy pocket guide for providers and Clinical Documentation Specialists. The focus of this collection is on the language and or wording that is necessary to provide greater detail in the patient chart. It does not include codes, but space has been included to allow for personal notes. The content is based on and arranged according to the chapters of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). 2
3 Table Of Contents Clinical Documentation Improvement Tips
4 Oncology Anemia in Chronic Disease Blood Loss Anemia Nutritional Anemia Other Drug Included Blood Disorders Drug Underdosing Leukemia Neoplasms Obesity Tobacco Use Disorder
5 Anemia in Chronic Disease Document the chronic disease and link it to the anemic: Anemic due to chronic kidney disease Anemic due to colon cancer
6 Blood Loss Anemia Document when appropriate: Anemia due to acute blood loss Anemia due to chronic blood loss If acute blood loss anemia is due to blood loss during surgery: Documentation of postoperative anemia is not enough Document instead postoperative anemia due to acute blood loss When it is your clinical judgment that the surgery resulted in an expected amount of blood loss, no diagnosis of acute blood loss is needed.
7 Nutritional Anemia Document iron deficiency anemia by type: Sideropenic iron deficiency anemia Iron deficiency due to inadequate dietary iron intake Document vitamin B12 type, such as: Due to intrinsic factor deficiency Vitamin B12 malabsorption Document folate deficiency type, such as: Due to diet Drug induced Document other nutritional types, such as: Protein deficiency
8 Other Drug Induced Blood Disorders Document cause and effect, for example: Agranulocytosis due to sulfasalazine Pancytopenia due to chemotherapy
9 Drug Underdosing Document type: Intentional versus unintentional Document reason for underdosing, such as: Financial hardship or age related dementia
10 Leukemia Document: Acute versus chronic Document specific type, for example: Acute lymphoblastic Chronic lymphoblastic of B-cell type Prolymphoblastic of B-cell type Hairy cell Adult T-cell Document remission-relapse status for each patient visit: Not having achieved remission In remission In relapse
11 Neoplasms Document specific site Document laterality: Right, left and/or bilateral Detail when a patient has presented for a specific treatment related to the neoplasm (e.g., surgical removal, chemotherapy, immunotherapy, radiation therapy) Document morphology: Malignant Benign In situ Uncertain or unspecified behavior
12 Obesity Document etiology: Due to excess calories or nutritional Due to drugs Other, for example, due to thyroid or pituitary disorder If morbidly obese, also document if with alveolar hypoventilation. Document BMI
13 Tobacco Use Disorder Document type: Cigarettes Chewing tobacco Other Delineate between: Tobacco use/abuse Tobacco dependence Document state of dependence: In remission With or without withdrawal Document if used during pregnancy, child birth, puerperium Describe history, including product and time
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