Cracking the Code

Complications After Receiving Brachytherapy Treatment

There are times where a cancer patient may be admitted for chemotherapy, radiation therapy, or immunotherapy and develops complications after admission. Coding instructions from ICD-10-CM Official Guidelines for Coding and Reporting state that the principal diagnosis is the encounter for the chemotherapy, radiation therapy, or immunotherapy followed by any codes for the complications as secondary diagnoses.

However, there are other times when a cancer patient may be admitted for insertion or implantation of radioactive elements (i.e. brachytherapy or external beam radiation) and develops complications after admission. For these types of encounters, coding guidelines instructs coders to list the appropriate code for malignancy followed by any codes for the complications as secondary diagnoses.

Q: A 57-year-old woman with cervical cancer presents to the cancer treatment center for brachytherapy radiation. After receiving the treatment, the patient started experiencing diarrhea and nausea.
A: C53.9, malignant neoplasm of cervix uteri, unspecified, R19.7, diarrhea, unspecified, and R11.0, nausea
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.C.2.e.3.
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