March 1, 2010

Coding for Multiple Myeloma
For The Record
Vol. 22 No. 4 P. 28

Multiple myeloma is a plasma cell cancer that involves a type of white blood cell in bone marrow. It results in bone erosion and malfunctioning of the bone marrow and the immune system, which may lead to anemia and infections.

Multiple myeloma is classified to ICD-9-CM code 203.0. A fifth digit is required to identify whether the condition is in remission, in relapse, or without mention of having achieved remission. Code V10.79 identifies a patient with a personal history of multiple myeloma. A diagnostic statement of multiple myeloma with bone metastasis is assigned to code 203.00 only. No additional code for the bone metastasis is necessary since bone involvement is a part of the disease process (AHA Coding Clinic for ICD-9-CM, 1989, fourth quarter, page 10). In addition, malignant neoplasms classifiable to categories 200 to 208, Lymphomas and Hematopoietic Tissue Malignancies, and stated as secondary or metastatic remain within this category range and are not coded to category 196 (AHA Coding Clinic for ICD-9-CM, 1985, May-June, page 4).

Signs and Symptoms
Symptoms may not be present in the early disease stages but may occur as the disease progresses. Some common signs and symptoms include bone pain, usually in the back, pelvis, ribs, and skull; the presence of abnormal proteins (produced by myeloma cells) in blood or urine called monoclonal or M-proteins (If found in urine, may be referred to as Bence Jones proteins.); a high level of calcium in the blood that may cause excessive thirst and urination, mental confusion, constipation, and nausea; anemia that causes fatigue; pathological or nontraumatic bone fractures; repeat infections such as pneumonia, bladder or kidney infections, sinusitis, or shingles; weight loss; and weakness or numbness in the legs.

Diagnosis
If the physician suspects the patient has multiple myeloma, these tests may be performed: blood tests to measure blood cell counts and levels of calcium, uric acid, creatinine, beta-2 microglobulin, and the percentage of plasma cells; x-rays to show bone lesions; MRI; a CT or PET scan; and/or a bone marrow biopsy to check for myeloma cells.

A bone marrow biopsy (41.31) should not be confused with a bone biopsy (77.4x). It is rare to perform both types of biopsies during the same procedure since each one is a diagnostic tool for different illnesses. Before assigning a code for a bone biopsy, review the record for medical intent and a signed consent stating that a bone biopsy will be performed. Also review the pathology report for bone core, cortical bone analysis, or core specimen demineralization. However, the pathology report may indicate that a bone core examination took place when the procedure was actually a bone marrow biopsy. To ensure appropriate procedure code assignment in this situation, it is necessary to review physician intent and reason for the procedure.

Complications
A patient with multiple myeloma may experience complications, including impaired immunity, osteoporosis, fractures, kidney function problems, or anemia.

If a patient with multiple myeloma experiences a pathological or stress fracture, assign the appropriate code for the fracture and for the multiple myeloma. Sequencing will depend on the circumstances of admission. “Although manifestations of the disease are expected, they are not always inherent in the disease process” (AHA Coding Clinic for ICD-9-CM, 1996, first quarter, page 16).

Treatment
Treatment will help relieve pain, control complications, stabilize the condition, and slow the disease progression and may include the following:

• medications such as bortezomib (Velcade), thalidomide (Thalomid), and lenalidomide (Revlimid);

• chemotherapy (99.25) taken orally or intravenously to kill myeloma cells;

• radiation therapy (92.2x) that targets myeloma cells and kills them; and/or

• bone marrow transplantation (41.0x) that replaces bone marrow with healthy bone marrow either from a donor (allogeneic) or from the patient (autologous).

Coding and sequencing for multiple myeloma are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.