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How to Code Lung Cancer & Drain Care in ICD-10​

• Victoria Jones

How to Code Lung Cancer & Drain Care in ICD-10


Scenario:

The patient is being admitted to home health following surgery for left lower lobe lung cancer and will need dressing changes, care for his surgical drain, and teaching on newly prescribed oxygen use. His physician plans to begin chemo immediately.

Codes:

M1021a – Z48.3 Aftercare following surgery for neoplasm

M1023b – C34.32 Malignant neoplasm of lower lobe, left lung

M1023c – Z48.03 Encounter for change or removal of surgical drain

M1023d – Z48.01 Encounter for change or removal of surgical dressing

M1023e – Z99.81 Dependence on supplemental oxygen

Rationale:

Because the primary focus of care by the home health agency is the patient’s recent surgery, this is coded first. The cancer is considered still present as treatment via chemo is continuing, so the specific neoplasm code is used next. If physician documentation would have indicated that the surgery eradicated the cancer and no longer required treatment, a history code would have been used instead. Lastly the codes for drain care, dressing care, and oxygen use follow.

Victoria Jones, RN, HCS-D, HCS-H, COS-C

Assistant Director of Quality

Victoria joined PPS Plus after gaining experience in the emergency and critical care fields. Born in Florida, she has lived all along the east coast, as well as California, thanks to her husband serving in the US Navy. However, Victoria considers the Mississippi Gulf Coast her home. When she’s not reviewing patient charts, Victoria enjoys volunteering for local animal rescue organizations, shopping, and of course, spending time with her family and three children.