April 30, 2007

Coding for Pituitary Tumors
For The Record
Vol. 19 No. 9 P. 36

Pituitary tumors are abnormal growths that develop in the pituitary gland. They can make the gland produce excessive amounts of hormone or restrict it from producing hormones. Most pituitary tumors are benign adenomas—slow-growing tumors that don’t metastasize. However, they can damage normal pituitary tissue and interfere with hormone production.

Another type of pituitary tumor is invasive adenomas, which may spread to outer covering of brain, bones of the skull, or sinus cavity near the pituitary gland. Pituitary tumors may also be carcinomas, which are malignant and may spread to the central nervous system and beyond. Occasionally, other primary cancers, such as breast and lung, metastasize to the pituitary gland.

The following are the ICD-9-CM code assignments for pituitary tumors, depending on their behavior classification:

• Malignant, primary—194.3;

• Malignant, secondary—198.89;

• Carcinoma in situ—234.8;

• Benign—227.3;

• Uncertain behavior—237.0; and

• Unspecified—239.7.

Types of Pituitary Tumors
Pituitary tumors can be considered either functioning or nonfunctioning tumors. Functioning tumors are tumors that produce one or more pituitary hormones. Nonfunctioning tumors don’t produce hormones.

Each type causes different symptoms, depending on the hormone produced. Adrenocorticotropic hormone (ACTH)-producing tumors occur when the ACTH is produced, stimulating the adrenal glands to make the hormone cortisol. When too much cortisol is produced, Cushing’s syndrome (255.0) occurs. Signs and symptoms of Cushing’s syndrome include weight gain around the midsection and upper back, facial roundness, a hump on upper part of the back, proximal myopathy, thinning of the skin, hirsutism, osteopenia, and muscle weakness.

Growth hormone-producing tumors produce excess growth hormone, which causes acromegaly (253.0). Signs and symptoms of acromegaly include coarsening facial features, enlarged hands and feet, heart problems, accelerated and excessive growth in children, carpal tunnel syndrome, obstructive sleep apnea, osteoarthritis and arthralgia, and excessive sweating.

Prolactin-producing tumors occur with the overproduction of prolactin (prolactinoma), which causes a decrease in the normal levels of sex hormones. It may cause hyperprolactinemia (253.1). Signs and symptoms of prolactinoma include oligomenorrhea or amenorrhea, reduced fertility, loss of libido, and erectile dysfunction.

Thyroid-stimulating hormone-producing tumors cause the thyroid gland to make too much of the hormone thyroxine, which is a rare cause of hyperthyroidism (242.8x). Signs and symptoms of hyperthyroidism include accelerated metabolism, sudden weight loss, rapid/irregular heartbeat, sweating, nervousness, irritability, tremor, and insomnia.

For coding purposes, first assign the code for the pituitary tumor based on the documented behavior, followed by the code(s) for any functional activity as secondary diagnoses. Other common signs and symptoms of functioning and nonfunctioning pituitary tumors include headache, vision change, difficulty in moving the eyes, seizures, clear and watery nasal drainage, hair loss, intolerance to cold, and weight change.

Diagnosis
To aid in a pituitary tumor diagnosis, the physician may order blood tests to detect an overproduction or deficiency of hormones. The physician may also order a CT scan or MRI. Vision testing may be done to see if the pituitary tumor has impaired the patient’s eyesight or peripheral vision. Finally, bone imaging may be performed in children to determine if the bone growth is normal.

Staging
After the diagnosis is confirmed, pituitary tumors are placed in one of the following stages based on size and invasion of the tumor:

• Stage 1 — microadenomas (less than or equal to 10 millimeters [mm]) without sella expansion

• Stage 2 — macroadenomas (exceeding 10 mm) and may extend above the sella

• Stage 3 — macroadenomas with enlargement and invasion of the floor or suprasellar extension

• Stage 4 — destruction of the sella

Treatment
Treatment depends on the type of tumor, its size, and how far it has grown into the brain. Surgical excision of the tumor is one option. There are two main techniques used in the excision of the pituitary tumor. One is transsphenoidal hypophysectomy, which involves the excision of the tumor through the nose and sinuses without an external incision. This approach, which may also be documented as transseptal or transnasal, is better on smaller tumors. Another technique is transcranial hypophysectomy. This approach excises the tumor through an incision in the upper part of the skull. One of the following codes will be assigned for this surgery:

• 07.61, Partial excision of pituitary gland, transfrontal (transcranial) approach;

• 07.62, Partial excision of pituitary gland, transsphenoidal approach;

• 07.64, Total excision of pituitary gland, transfrontal (transcranial) approach; or

• 07.65, Total excision of pituitary gland, transsphenoidal approach.

If the approach is not documented, assign code 07.63 for partial excision of the pituitary gland and code 07.69 for total excision of the pituitary gland.

Radiation therapy (92.2x) is another treatment option. It may be used in conjunction with surgery or as a stand-alone treatment. The patient typically receives small increments of radiation, usually fives times per week for four to six weeks on an outpatient basis. This method may damage remaining normal pituitary cells and normal brain tissue. Therefore, the physician may choose to perform gamma knife radiosurgery (92.32 + 93.59). This procedure focuses radiation beams precisely on the tumor, decreasing the risk of damage to normal tissue.

Medications are another treatment option. They can block excess hormone secretion and may be able to shrink certain types of pituitary tumors. Coding and sequencing for pituitary 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 nearly 5,000 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.