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How to Document Ovarian Cancer Using ICD-10 and CPT Medical Codes

by | Jun 28, 2018 | Medical Coding News, Resources | 0 comments

Ovarian cancer, considered as the tenth most common cancer among women in the United States, refers to any cancerous growth that appears in the ovary (reproductive glands). It occurs when abnormal cells in the ovary begin to multiply out of control and form a tumor. Most ovarian cancers develop initially in the epithelium, or outer lining of the ovary and often come with symptoms such as – abdominal bloating and pain, weight loss, abnormal fullness after eating, frequent urination, difficulty eating, discomfort in the pelvis area and changes in bowel habits, such as constipation. If left untreated, this tumor can spread to other parts of the body. With appropriate and timely treatment, the serious complications caused by ovarian cancer can be reversed. It is important for physicians to instruct their medical coding outsourcing service providers or clinical staff to be specific and document their diagnosis and medical procedures with accurate medical codes.

Reports suggest that about 22,000 women in the US will receive a diagnosis of ovarian cancer yearly and around 14,000 are expected to die from this disease (2017 statistics). The exact cause of ovarian cancer is not clear; however physicians have identified certain factors that can increase the risk of the disease which include – age, family history, reproductive history, the use of certain fertility drugs or hormone therapies, endometriosis and obesity.

Diagnosis and Treatment

Ovarian cancer can be hard to detect in the early stages as most signs and symptoms do not appear until the disease has progressed fully. Early and timely diagnosis helps in better treatment. It is estimated that early diagnosis of ovarian cancer (in the primary stages) leads to 94 percent chance of survival for at least 5 years. A woman’s lifetime risk for developing ovarian cancer is 1 in 75.

There is no specific routine diagnostic screening test available for detecting ovarian cancer. However, physicians may recommend a series of imaging tests/procedures such as transvaginal ultrasound (TVUS), abdominal and pelvic CT scan, blood tests, laparoscopy, MRI scan, colonoscopy and abdominal fluid aspiration in order to determine the size, shape and structure of your ovaries. In addition, biopsy will be performed to remove the tumor or part of the tumor to examine for the presence of cancer cells. The type of treatment for this cancer may depend on how far the cancer has spread. Treatment methods for this condition may include – chemotherapy, radiation, hormone therapy, targeted therapy and surgery to stage the cancer and remove the tumor.

Radiology medical coding involves using the specific ICD-10 diagnosis codes, CPT procedure codes and HCPCS codes for reporting ovarian cancer on your medical claims.

ICD-10 Codes to Indicate Diagnosis of Ovarian Cancer

  • C56 – Malignant neoplasm of ovary
  • C56.1 – Malignant neoplasm of right ovary
  • C56.2 – Malignant neoplasm of left ovary
  • C56.9 – Malignant neoplasm of unspecified ovary
  • C79.6 – Secondary malignant neoplasm of ovary
  • C79.60 – Secondary malignant neoplasm of unspecified ovary
  • C79.61 – Secondary malignant neoplasm of right ovary
  • C79.62 – Secondary malignant neoplasm of left ovary
  • Z80.41 – Family history of malignant neoplasm of ovary
  • Z15.02 – Genetic susceptibility to malignant neoplasm of ovary

CPT Codes

The standard treatment procedure for ovarian cancer for women involves a debulking surgery (performed by a gynecologic oncologist) wherein the tumor is removed as much as possible. This is followed by a combination of platinum compound (usually cisplatin or carboplatin) and taxane such as paclitaxel (Taxol®) or docetaxel (Taxotere®) chemotherapy drugs given as an IV (put into a vein) on an every 3 to 4 week schedule.

CPT Codes for Debulking Surgery

  • 58940 – Oophorectomy, partial or total, unilateral or bilateral
  • 58943 – Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy
  • 58950 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy
  • 58951 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy
  • 58952 – Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking
  • 58953 – Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking
  • 58954 – Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited paraaortic lymphadenectomy
  • 58956 – Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy
  • 58957 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed
  • 58958 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy

CPT Codes for Chemotherapy Administration

  • 96413 – Chemotherapy administration, IV infusion; up to one hour, single or initial substance/drug
  • 96415 – Chemotherapy administration, IV infusion; each additional hour 1-8 hours
  • 96416 – Chemotherapy administration, IV infusion; initiation of prolonged chemotherapy infusion (more than 8 hours) requiring the use of portable/implantable pump
  • 96417 – Chemotherapy administration, IV infusion; each additional sequential infusion, up to one hour
  • 96422 – Chemotherapy, intra-arterial infusion technique up to 1 hour
  • 96423 – Chemotherapy, intra‐arterial infusion technique; each additional hour ((List separately in addition to code for primary procedure)
  • 96425 – Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump
  • 96440 – Chemotherapy administration into pleural cavity, requiring and including thoracentesis
  • 96446 – Chemotherapy administration into the peritoneal cavity via indwelling port or catheter

HCPCS Codes

  • J9060 – Injection, cisplatin, powder or solution, 10 mg
  • J9045 – Injection, carboplatin, 50 mg
  • J9264 – Injection, paclitaxel protein-bound particles, 1 mg
  • J9171 – Injection, docetaxel, 1 mg

For accurate and timely medical billing and claims submission, radiology practices providing treatment for ovarian cancer can outsource their medical tasks to an experienced medical billing company that offers the services of AAPC-certified coding specialists.

The general outlook for ovarian cancer varies, depending on its stage and type. Generally, cancer in the ovaries is very rare among young women. As per estimates from the Ovarian Cancer Research Fund Alliance, the median age of a diagnosis is 63 years. The risk of developing this condition could be higher if you have a strong family history of ovarian cancer or if you carry certain genetic mutations. Therefore, it is important to report any unusual symptoms to your physician immediately.

When the symptoms are persistent and do not resolve with normal interventions (such as physical exercise, diet changes, body rest, laxatives) it is imperative for a woman to visit her physician. In most cases, ovarian cancer symptoms are described as vague and silent and occur in advanced stages when tumor growth creates pressure on the bladder and rectum, and fluid begins to form. It is estimated that about 19 percent of ovarian cancer is diagnosed in its early stages. The sooner you identify the symptoms (in its early stages); the better will be its further treatment and your chances of survival.