EmailCancer confirmed on pathology report without documentation on endoscopy report
Publication Date: December 2018
Implementation Date: 1/06/2021
ICD 10 AM Edition: Tenth edition
Query Number: 3436
Patient presented for same day Endobronchial ultrasound bronchoscopy (EBUS).
Indication on EBUS: for Mediastinal & hilar lymphadenopathy.
Body of the EBUS report: station 7 examined and sampled with 3 passes.
Sample sent for cytopathology.
Cytopathology results:
Transbronchial needle aspiration (TBNA) subcarina: Carcinoma, immunochemistry consistent with poorly differentiated squamous cell carcinoma
Bronchial washings: carcinoma
There is no documentation on the EBUS report of a diagnosis or linking the indication to the finding.
We have different opinions within our coding team regarding the principal diagnosis for this episode and which ACS should be applied.
Some coders believe ACS 0051 Same-day endoscopy - diagnostic should be applied given the episode is for a same day bronchoscopy, while other coders believe ACS 0010 General abstraction guidelines should be applied.
Can VICC please:
1) Confirm the principal diagnosis for this episode
2) Clarify the ACS applied AND why
3) Confirm the procedure code based on sampling being documented on EBUS and cytopathology analysed (TBNA).
Indication on EBUS: for Mediastinal & hilar lymphadenopathy.
Body of the EBUS report: station 7 examined and sampled with 3 passes.
Sample sent for cytopathology.
Cytopathology results:
Transbronchial needle aspiration (TBNA) subcarina: Carcinoma, immunochemistry consistent with poorly differentiated squamous cell carcinoma
Bronchial washings: carcinoma
There is no documentation on the EBUS report of a diagnosis or linking the indication to the finding.
We have different opinions within our coding team regarding the principal diagnosis for this episode and which ACS should be applied.
Some coders believe ACS 0051 Same-day endoscopy - diagnostic should be applied given the episode is for a same day bronchoscopy, while other coders believe ACS 0010 General abstraction guidelines should be applied.
Can VICC please:
1) Confirm the principal diagnosis for this episode
2) Clarify the ACS applied AND why
3) Confirm the procedure code based on sampling being documented on EBUS and cytopathology analysed (TBNA).
Response
VICC advises that ACS 0051 Same-day endoscopy - diagnostic applies to the scenario cited because the episode is for a same day diagnostic endoscopy and there is no documented principal diagnosis.
In the absence of a documented causal link between the indication/symptom and the findings, as per point 1.2 of ACS 0051, assign a code for the indication/symptom as the principal diagnosis and assign codes for all findings as additional diagnoses.
In the scenario cited, the principal diagnosis is R59.1 Generalised enlarged lymph nodes following Index entry Lymphadenopathy (generalised). The carcinoma is coded as an additional diagnosis.
Based on the documentation provided, VICC advises the following intervention codes:
41898-05 [543] Bronchoscopy
30688-00 [1949] Endoscopic ultrasound (EBUS).
41898-04 [544] Endoscopic [needle] biopsy of bronchus can be assigned if the procedure has been documented on the EBUS report; it cannot be assigned from documentation of bronchial washings on the cytology report alone.
Whilst VICC considers that Transbronchial Needle Aspiration (TBNA) is a biopsy as per VICC #3385 Fine needle aspiration (FNA) of lymph node, further specification of the site is needed before a code can be assigned. In the body of the EBUS report provided, the documentation 'sampling of station 7' does not describe a site.
Note: This query was originally published in December 2018 and was retired 30June 2020. The query has been reinstated as VICC considers the advice is still current for Eleventh Edition ICD-10-AM.
In the absence of a documented causal link between the indication/symptom and the findings, as per point 1.2 of ACS 0051, assign a code for the indication/symptom as the principal diagnosis and assign codes for all findings as additional diagnoses.
In the scenario cited, the principal diagnosis is R59.1 Generalised enlarged lymph nodes following Index entry Lymphadenopathy (generalised). The carcinoma is coded as an additional diagnosis.
Based on the documentation provided, VICC advises the following intervention codes:
41898-05 [543] Bronchoscopy
30688-00 [1949] Endoscopic ultrasound (EBUS).
41898-04 [544] Endoscopic [needle] biopsy of bronchus can be assigned if the procedure has been documented on the EBUS report; it cannot be assigned from documentation of bronchial washings on the cytology report alone.
Whilst VICC considers that Transbronchial Needle Aspiration (TBNA) is a biopsy as per VICC #3385 Fine needle aspiration (FNA) of lymph node, further specification of the site is needed before a code can be assigned. In the body of the EBUS report provided, the documentation 'sampling of station 7' does not describe a site.
Note: This query was originally published in December 2018 and was retired 30June 2020. The query has been reinstated as VICC considers the advice is still current for Eleventh Edition ICD-10-AM.
