*
The patient with "Assessment A" had been previously coded by another coder at admit as C61- Malignant neoplasm of prostate ... I'm interpreting the following assessment as C79.82- Secondary malignant neoplasm of genital organ.
My general understanding of prostate cancer is that it will begin at the prostate and metastasize elsewhere (the spine, bones, etc.). My confusion is: Is "Metastatic prostate cancer" saying the prostate cancer is spreading elsewhere (as primary), or that the prostate cancer itself is metastatic (secondary).
I have other examples as well that have seemed to confuse me a bit. Can someone please advise on how I should read the cancer dictation, and possibly how to code these encounters for the cancer?
ASSESSMENT A:
1. Metastatic prostate cancer.
2. Thoracic spinal cord compression with metastatic prostate cancer status post laminectomy and fusion.
3. Incomplete paraparesis.
4. Neurogenic bladder.
5. Neurogenic bowel.
6. Leukocytosis.
ASSESSMENT B:
1. Incomplete quadriparesis secondary to metastatic prostate cancer of the thoracic spine.
2. T2-T5 laminectomy for excision of metastases with focal fusion.
3. Widely metastatic prostate cancer to the bone.
4. Dyslipidemia.
5. Neurogenic bladder.
6. Neurogenic bowel
ASSESSMENT C:
1. Metastatic renal cell carcinoma to the T10 vertebral body, status post laminectomy and spinal
decompression.
2. Postoperative epidural hematoma, status post evacuation.
3. Neurogenic bladder.
4. Neurogenic bowel.
ANY help would be greatly appreciated, as I seem to have confused myself at this point.
Thanks,
-Erica
This entry passed through the Full-Text RSS service - if this is your content and you're reading it on someone else's site, please read the FAQ at http://ift.tt/jcXqJW.
Cancer coding primary vs. secondary - My confusion.