October 26, 2009

Coding for Brain Tumors
For The Record
Vol. 21 No. 20 P. 28

A brain tumor is a mass or growth of abnormal cells in the tissues of the brain. Primary brain tumors may be benign or malignant and originate in the brain. Malignant primary brain tumors are classified to ICD-9-CM category 191. The fourth-digit subcategory identifies the part of the brain involved:

• 191.0, Cerebrum, except lobes and ventricles, includes basal ganglia, unspecified lobe of cerebral cortex, corpus striatum, globus pallidus, hypothalamus, and thalamus.

• 191.1, Frontal lobe.

• 191.2, Temporal lobe, which includes hippocampus and uncus.

• 191.3, Parietal lobe.

• 191.4, Occipital lobe.

• 191.5, Ventricles, which includes choroids plexus and ventricle floor.

• 191.6, Cerebellum, not otherwise specified, which includes cerebellopontine angle.

• 191.7, Brain stem, which includes cerebral peduncle, medulla oblongata, midbrain, and pons.

• 191.8, Other parts of brain, which includes corpus callosum and tapetum. This code also includes a malignant neoplasm of contiguous or overlapping sites of brain whose point of origin cannot be determined.

• 191.9, Brain unspecified and cranial fossa unspecified.

Benign neoplasms of the brain are classified to code 225.0.

Secondary brain tumors (198.3), which are more common, start somewhere else in the body and metastasize to the brain. Common primary sites that metastasize to the brain include breast cancer, colon cancer, kidney cancer, lung cancer, melanoma, neuroblastoma, and sarcoma.

Vasogenic edema (cerebral edema) is a buildup of fluid in the brain and is commonly present with a brain tumor. It is appropriate to assign code 348.5, Cerebral edema, as a secondary diagnosis when it is present with a brain tumor and the physician documents the clinical significance of the cerebral edema/vasogenic edema and the condition was evaluated, monitored, or treated (AHA Coding Clinic for ICD-9-CM, 2009, third quarter, page 8). Do not assign a code for the cerebral edema based strictly on the diagnostic study findings (eg, CT or MRI).

Signs and Symptoms
The signs and symptoms of a brain tumor, which depend on the size, location, and rate of growth, may include frequent and severe headaches; unexplained nausea and vomiting; vision problems; loss of sensation or movement in arms or legs; balance, speech, or hearing problems; confusion; personality/behavior changes; seizures; and hormonal disorders.

Types of Brain Tumors
The following are common types of brain tumors and are named from the type of cells involved:

• Acoustic neuroma (schwannoma) — Malignant is classified to code 192.0 and benign is classified to 225.1.

• Astrocytoma (also known as glioma) includes anaplastic and glioblastoma (category 191).

• Ependymoma (category 191).

• Ependymoblastoma (category 191).

• Medulloblastoma (category 191).

• Meningioma (192.1).

• Neuroblastoma (category 191).

• Oligodendroglioma (category 191).

• Pineoblastoma (194.4).

Code assignment for the above types of brain tumor that are classified to category 191 depends on the tumor site.

Diagnosis
If a physician suspects a brain tumor, he or she will perform a neurologic exam to check vision, hearing, balance, coordination, and reflex. If the patient fails this exam, then the physician will order one or more of the following diagnostic studies: a CT scan; an MRI; an angiogram; an x-ray of the head and skull; magnetic resonance spectroscopy; single-photon emission computerized tomography; a positron emission tomography scan; and/or a biopsy of brain tissue.

Treatment
Treatment of a brain tumor depends on the type, size, grade, and location of the tumor. The patient may receive one or a combination of surgery, radiation therapy, and/or chemotherapy.

Coding and sequencing for brain tumors 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.