Can someone have a metastatic tumor without having a primary cancer? Thats goes back to the question, metastatic breast, thats all they say in the documentation. So, what do we need to translate that is? How do we code that? The answer is no. A metastatic tumor is always caused by cancer cells from another part of the body. So, if you say metastatic breast then we know that that cancer came from someplace else, right? A metastatic tumor is always caused by cancer cells from another body part.
It goes on to say, when that metastatic tumor is found first, the primary cancer can also be found, because theyll look under the microscope and theyll say, This is breast tissue, breast cells, cancer cells in the bone, so the primary site would be the breast and the secondary site would be the bone. Now, what if they havent determined from all of the tests what the primary is, but they know that the cells that are in the breast are not breast cells? They know it came from.
Someplace else but they havent determined where. what do you do? so thats a metastatic breast. They know because they looked at the cells, Pathology tells them its still a secondary cancer. However, in some patients this is underlined thats why I want you to pay attention a metastatic tumor is diagnosed but the primary tumor cannot be found, despite extensive tests. So, the pathologist knows that the diagnosed tumor, metastatic breast, is a secondary because.
Of the organ or the tissue in which the tumor was found is not the same as the cells that are cancerous. Thats when you know to code it as a secondary. If I just saw documentation that said metastatic breast I would lean towards that being secondary. Now, are you going to have more information? When youre doing risk adjustment coding, most of the MA plans and stuff will allow you to look through the entire years worth of documentation to find out, only for cancer, a higher specificity. They dont let you.
Do that with other diagnoses. But with cancer, when I worked for UHC, they did say thats the only diagnosis that you can use other encounters to determine the encounter that youre looking at what type of cancer or the highest specificity. Again, with risk adjustment rules changed; but when you have a diagnosis of metastatic cancer, I would start digging and snooping into the persons chart and see if you can get to a higher specificity, but with just plain.