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Whether it is the “Quality Standards for Filling Inpatient Medical Records (Interim)” or the “Medical Insurance Fund Settlement List Filling Standards”, the reporting rules for tumors are the most extensive, and the changes in the DRG grouping rules related to tumors are also significant (see the changes in the tumor department CHS-DRG version 1.1), this article summarizes and organizes the principles for selecting primary diagnoses related to tumors in the medical insurance settlement list, helping everyone deepen their understanding of the filling standards.
1. When inpatient treatment is aimed at malignant tumors, malignant tumors can potentially become the primary diagnosis.
1. Tumor Diagnosis:C codes as primary diagnosis
The purpose of hospitalization is to clarify the tumor diagnosis (such as malignancy degree, tumor extent), or to confirm the tumor for certain procedures (such as: puncture biopsy, etc.), even if radiotherapy or chemotherapy has been performed, the primary (or secondary) site of the malignant tumor is still chosen as the primary diagnosis.
2. Tumor Surgery:C codes as primary diagnosis
When a surgical resection is performed on a malignant tumor (including primary or secondary sites), even if preoperative and/or postoperative radiotherapy or chemotherapy has been performed, the malignant tumor is still chosen as the primary diagnosis.
3. Tumor Radiotherapy, Chemotherapy, Immunotherapy:C codes as other diagnoses
If the patient is hospitalized specifically for chemotherapy, radiotherapy, or immunotherapy for malignant tumors, malignant tumor chemotherapy (code Z51.1), radiotherapy (code Z51.0), or immunotherapy (code Z51.8) should be selected as the primary diagnosis, with malignant tumors as other diagnoses.
If the patient undergoes multiple treatments during one hospitalization, the primary diagnosis should be correctly selected based on the specific situation according to general principles (the most medical resource consumption, the greatest harm to patient health, the longest impact on hospitalization time).
4. Secondary Tumor Issues:C codes as primary diagnosis
Inpatient treatment is aimed at the malignant tumor at the secondary site, with the malignant tumor at the secondary site as the primary diagnosis.
If the primary tumor still exists, the primary tumor is listed as another diagnosis; if the primary tumor has been previously removed or eradicated, the personal history of malignant tumors is listed as another diagnosis to indicate the primary site of the malignant tumor.
Example 1: Hospitalization primarily for treatment of brain metastasis from lung cancer (not surgically removed). Primary diagnosis: Brain secondary malignant tumor C79.3 Other diagnosis: Lung malignant tumor C34.9Example 2: Hospitalization primarily for treatment of brain metastasis from lung cancer (surgically removed). Primary diagnosis: Brain secondary malignant tumor C79.3 Other diagnosis: Personal history of lung malignant tumor Z85.1
2. When treatment is only for complications caused by malignant tumors (or for the treatment of malignant tumors), select the complication as the primary diagnosis, with the malignant tumor as another diagnosis.
If there are multiple malignant tumors, report them in order of malignancy severity.
1. Hospitalization for Treatment of Anemia
1. Anemia caused by malignant tumors, and only anemia is treated
Primary diagnosis: Anemia due to tumor disease
Other diagnosis: Malignant tumor
2. Anemia caused by chemotherapy, radiotherapy, and immunotherapy, and only anemia is treated
Primary diagnosis: Anemia
Other diagnosis: Malignant tumor
2. SimultaneousRadiotherapy and Chemotherapy and Treatment of Radiotherapy and Chemotherapy Complications
3. When the patient is hospitalized for chemotherapy, radiotherapy, and immunotherapy, and complications arise during treatment, such as: uncontrollable nausea, vomiting, or dehydration
Primary diagnosis: Chemotherapy, radiotherapy, or immunotherapy
Other diagnosis: Complications such as nausea, vomiting, or dehydration (hospitalization condition is “4”)
3. Purely Treating Complications
4. When the patient is hospitalized for complications caused by malignant tumors (such as dehydration), and only that complication (such as dehydration) is treated (intravenous fluid supplementation)
Primary diagnosis: Complications such as dehydration (hospitalization condition is “1”)
Other diagnosis: Malignant tumor
3. For widely metastatic malignant tumors without specified sites, use code C79.9; this diagnosis is only used when the patient has metastatic lesions and the primary and secondary sites are unknown.
When there is a known diagnosis of secondary site tumors, they should be coded separately.
Analysis:Inpatient medical records generally cannot be coded broadly as C79.9, because patients can usually find specific metastatic sites through examination. If the doctor diagnoses: liver cancer with multiple metastases, the coder should review the medical record, find out which specific sites have metastases, and convert them into codes one by one.
4. Malignant Tumors During Pregnancy
Primary diagnosis: Malignant tumors during pregnancy, childbirth, and the puerperium (O99.8)
Other diagnosis: Malignant tumor C code
Analysis:Pregnancy, childbirth, and the puerperium are strongly prioritized classification chapters, which is a group of people that the state focuses on. Therefore, diseases combined with pregnancy, childbirth, and the puerperium should be primarily classified with O codes, and the involved malignant tumors should be placed as other diagnoses.
5. When a malignant tumor patient dies during hospitalization, the primary diagnosis should be correctly selected based on the specific circumstances of this hospitalization according to the above requirements.
Analysis:For deaths due to malignant tumors, one cannot simply revert to the original tumor code C code based on traditional thinking; the primary diagnosis should reflect the main treatment situation during this hospitalization, for example, if the patient came for chemotherapy, chemotherapy should be selected as the primary diagnosis.
Source: DRG Workers
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