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Tumor Tip of the Week-Diagnostic Confirmation

Scenario:  4-10-2020 CT Abdomen/Pelvis: Bilobed hypoenhancing mass within the pancreatic body/tail compatible with a primary pancreatic malignancy. Metastatic disease could have a similar appearance.

04-09-2020 CA 19-9    28,600 U/mL   HIGH

Managing Physician Statement: Metastatic cancer most likely pancreatic origin. I had an extensive discussion with the patient and his wife. They are both aware that he has incurable disease and have elected not to pursue additional diagnostic workup or treatment. He wishes to go home with hospice care. No further workup done.

Question:  How would diagnostic confirmation be coded?

  • 5 Positive laboratory test/marker study A clinical diagnosis of cancer is based on laboratory tests/marker studies which are clinically diagnostic for cancer
  • 7 Radiography and other imaging techniques without microscopic confirmation The malignancy was reported by the physician from an imaging technique report only

Answer:  7 Radiography and other imaging techniques without microscopic confirmation The malignancy was reported by the physician from an imaging technique report only

Rationale: Although the CA19-9 was really high, it does not indicate the cancer is from the pancreas or that there is even cancer.  While it is common to have elevated CA19-9 in hepatopancreatobiliary cancers, it is not diagnostic.  The diagnosis was based on the Ct scan. 

For a great discussion on diagnostic confirmation, please refer to this article Why Are Registrars Using Diagnostic Confirmation Code 4, 5 or 9 in the  January 2020  FCDS Monthly Memo. https://fcds.med.miami.edu/memos/2020_01memo.pdf

Diagnostic Confirmation = 5 should NOT be USED with two rare exceptions; positive alpha–fetoprotein for liver cancer without biopsy or abnormal protein electrophoresis spike for multiple myeloma. These tests are very rarely used in the absence of positive biopsy and/or imaging. And, today we see these two types of neoplasms almost always with a positive biopsy or positive imaging – and almost never with only a lab test. We are seeing this code being assigned with increased frequency when registrars think one of the new genetic tests or other some clarifying but non-diagnostic lab tests suggests a cancer is present or a more specific histology should be coded. Cancers are very rarely diagnosed only on a laboratory test or genetic testing. This may change in the future. But today, these tests only provide clarification of histologic type or subtype and are not the means for establishing the diagnosis of cancer…only a way to clarify or establish a better histology code. Please be cautious when using this particular code.

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