malignant neoplasms of head, neck, lip, oral cavity pharynx · malignant neoplasms of head, neck,...

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1 © Copyright 2015; Revised 9/24/15 MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY & PHARYNX DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use addiƟonal code to idenƟfy alcohol abuse and dependence Exposure to environmental tobacco smoke Exposure to tobacco smoke in perinatal period History of tobacco OccupaƟonal exposure to environmental tobacco smoke Tobacco dependence Tobacco use Malignant Neoplasm of BASE OF TONGUE C01 * Document alcohol/tobacco use Malignant Neoplasm of PARODID GLAND C07 * Document alcohol/tobacco use Malignant Neoplasm of LIP 0 External upper lip 1 External lower lip 2 External lip, unspecied 3 Upper lip, inner aspect 4 Lower lip, inner aspect 5 Lip, unspecied, inner aspect 6 Commissure of lip, unspecied 8 Overlapping sites of lip 9 Unspecied * Document alcohol/ tobacco use C00. C02. Malignant Neoplasm of OTHER & UNSPECIFIED PARTS OF TONGUE 0 Dorsal surface 1 Border 2 Ventral surface 3 Anterior twothirds of tongue, part unspecied 4 Lingual tonsil 8 Overlapping sites of tongue 9 Unspecied * Document alcohol/tobacco use Malignant Neoplasm of GUM 0 Upper gum 1 Lower gum 9 Unspecied * Document alcohol/tobacco use C03. Malignant Neoplasm of FLOOR OF MOUTH 0 Anterior 1 Lateral 8 Overlapping sites 9 Unspecied * Document alcohol/ tobacco use C04. Malignant Neoplasm of PALATE 0 Hard palate 1 SoŌ palate 2 Uvula 8 Overlapping sites 9 Unspecied * Document alcohol/tobacco use C05. * Document alcohol/tobacco use C08. Malignant Neoplasm of OTHER & UNSPECIFIED MAJOR SALIVARY GLANDS 0 Submandibular gland 1 Sublingual gland 9 Unspecied Malignant Neoplasm of TONSIL 0 Fossa 1 Pillar (anterior & posterior) 8 Overlapping sites 9 Unspecied * Document alcohol/tobacco use C09. Malignant Neoplasm of OROPHARYNX 0 Vallecula 1 Anterior surface of epigloƫs 2 Lateral wall of oropharynx 3 Posterior wall of oropharynx 4 Branchial cleŌ 8 Overlapping sites 9 Unspecied * Document alcohol/tobacco use C10.

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Page 1: MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY PHARYNX · MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY & PHARYNX ... 2 ‐ Lateral wall of oropharynx ... HYPOPHARYNX 0

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© Copyright 2015; Revised 9/24/15

MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY & PHARYNX 

DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use addi onal code to iden fy      ‐ alcohol abuse and dependence      ‐ Exposure to environmental tobacco smoke      ‐ Exposure to tobacco smoke in perinatal period      ‐ History of tobacco      ‐ Occupa onal exposure to environmental tobacco smoke      ‐ Tobacco dependence      ‐ Tobacco use

Malignant Neoplasm of  

BASE OF TONGUE  C01 *  Document alcohol/tobacco use 

Malignant Neoplasm of  

PARODID GLAND  C07 *  Document alcohol/tobacco use 

Malignant Neoplasm of  

LIP  0 ‐  External upper lip 1 ‐  External lower lip 2 ‐ External lip, unspecified 3 ‐  Upper lip, inner aspect 4 ‐ Lower lip, inner aspect 5 ‐ Lip, unspecified, inner aspect 6 ‐ Commissure of lip, unspecified 8 ‐  Overlapping sites of lip 9 ‐ Unspecified 

*  Document alcohol/      tobacco use 

C00.

C02. Malignant Neoplasm of  

OTHER & UNSPECIFIED PARTS OF TONGUE  0 ‐  Dorsal surface  1 ‐  Border  2 ‐ Ventral surface  3 ‐  Anterior two‐thirds of tongue, part unspecified 4 ‐ Lingual tonsil 8 ‐  Overlapping sites of tongue 9 ‐ Unspecified 

* Document alcohol/tobacco use 

Malignant Neoplasm of  

GUM  0 ‐  Upper gum 1 ‐  Lower gum 9 ‐ Unspecified 

*  Document alcohol/tobacco use 

C03.

Malignant Neoplasm of  

FLOOR OF MOUTH  0 ‐  Anterior  1 ‐  Lateral  8 ‐ Overlapping sites  9 ‐ Unspecified 

*  Document alcohol/      tobacco use 

C04.

Malignant Neoplasm of  

PALATE  0 ‐  Hard palate 1 ‐  So  palate 2 ‐ Uvula 8 ‐ Overlapping sites  9 ‐ Unspecified 

*  Document alcohol/tobacco use 

C05.

*  Document alcohol/tobacco use 

C08. Malignant Neoplasm of  

OTHER & UNSPECIFIED MAJOR SALIVARY GLANDS  0 ‐  Submandibular gland 1 ‐  Sublingual gland 9 ‐ Unspecified 

Malignant Neoplasm of  

TONSIL  0 ‐  Fossa 1 ‐  Pillar (anterior & posterior) 8 ‐ Overlapping sites  9 ‐ Unspecified 

*  Document alcohol/tobacco use 

C09.

Malignant Neoplasm of  

OROPHARYNX  0 ‐  Vallecula 1 ‐  Anterior surface of epiglo s 2 ‐ Lateral wall of oropharynx 3 ‐ Posterior wall of oropharynx 4 ‐ Branchial cle  8 ‐ Overlapping sites  9 ‐ Unspecified 

*  Document alcohol/tobacco use 

C10.

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© Copyright 2015; Revised 9/24/15 

MALIGNANT NEOPLASMS OF LUNG ‐ RESPIRATORY & INTRATHORACIC ORGANS 

Malignant Neoplasm of  

THYMUS  C37

Malignant Neoplasm of  

PYRIFORM SINUS  C12 *  Document tobacco use 

Malignant Neoplasm of  

TRACHEA C33

*  Document alcohol/tobacco use 

Malignant Neoplasm of  

NASOPHARYNX  0 ‐  Superior wall  1 ‐  Posterior wall  2 ‐ Lateral wall  3 ‐ Anterior wall  8 ‐ Overlapping sites  9 ‐ Unspecified 

*  Document  tobacco use 

C11.

Malignant Neoplasm of  

HYPOPHARYNX  0 ‐  Postcricoid region 1 ‐  Aryepiglo c fold,        hypopharyngeal aspect 2 ‐ Posterior wall  8 ‐ Overlapping sites 9 ‐ Unspecified 

*  Document tobacco use 

C13.

Malignant Neoplasm of  

NASAL CAVITY & MIDDLE EAR  0 ‐  Nasal cavity 1 ‐  Middle ear 

C30.

Malignant Neoplasm of  

ACCESSORY SINUSES  0 ‐  Maxillary sinus 1 ‐  Ethmoidal sinus 2 ‐ Frontal sinus 3 ‐  Sphenoid sinus 8 ‐  Overlapping sites  9 ‐ Unspecified 

C31.

Malignant Neoplasm of  

LARYNX  0 ‐  Glo s 1 ‐  Supraglo s 2 ‐ Subglo s 3 ‐  Laryngeal car lage 8 ‐  Overlapping sites  9 ‐ Unspecified 

*  Document alcohol/tobacco use 

C32.

Malignant Neoplasm of  

HEART,  MEDIASTINUM & PLEURA  0 ‐  Heart  1 ‐  Anterior medias num 2 ‐ Posterior medias num 3 ‐  Medias num, part unspecified 4 ‐ Pleura 8 ‐  Overlapping sites of heart, medias num and pleura 

C38.

DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use addi onal code to iden fy      ‐ alcohol abuse and dependence      ‐ Exposure to environmental tobacco smoke      ‐ Exposure to tobacco smoke in perinatal period      ‐ History of tobacco      ‐ Occupa onal exposure to environmental tobacco smoke      ‐ Tobacco dependence      ‐ Tobacco use

0 ‐ Unspecified 1 ‐ Right 2 ‐ Le

 2 ‐ Middle lobe, bronchus or lung 

Malignant Neoplasm of  

BRONCHUS & LUNG  0 ‐ Main bronchus 1– Upper lobe, bronchus or lung 3 –Lower lobe, bronchus or lung 8 ‐ Overlapping sites of bronchus & lung 9 –Unspecified part of bronchus or lung

STOP

* Document tobacco use

C34.

Excludes Carcinoid & Kaposi’s 

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© Copyright 2015; Revised 9/24/15

METASTATIC DISEASE 

Secondary Malignant Neoplasm of 

OTHER &  UNSPECIFIED SITES 

 0 ‐ Unspecified urinary organs 1 ‐ Bladder 9 ‐ Other urinary organs 

 1‐ Bladder and other and      unspecified urinary organs 

 0 ‐ Kidney & Renal Pelvis 6 ‐  Ovary 7 ‐ Adrenal gland 

 2 ‐ Skin 9 ‐ Unspecified 

 1 ‐ Breast 2 ‐ Genital organs 9 ‐ Other 

 0 ‐ Unspecified 1 ‐ Right 2 ‐ Le  

 3– Brain and cerebral meninges 

 4– Other & unspecified parts of       nervous system 

 0 ‐ Unspecified 9 ‐ Other 

 5– Bone and bone marrow   1 ‐ Bone 2 ‐Bone marrow 

 8– Other specified sites 

STOP

C79.

 1 –Brain 2– Cerebral meninges 

Malignant Neoplasm of 

OTHER &  ILL‐DEFINED SITES 

 0 ‐ Unspecified 1 ‐ Right 2 ‐ Le  

 0 ‐ Head, face & neck 1‐  Thorax 2 ‐ Abdomen 3 ‐ Pelvis 8 ‐Other specified ill‐defined sites 

 4 ‐ Upper limb 5‐  Lower limb 

STOP

C76.

Malignant Neoplasm of  

MESOTHELIOMA  0 ‐ Pleura 1 ‐ Peritoneum 2 ‐ Pericardium 7 ‐ Other sites 9 ‐ Unspecified 

C45. Malignant Neoplasm of  

THYROID GLAND C73

Secondary Malignant Neoplasm of 

RESPIRATORY &  DIGESTIVE ORGANS 

 0 ‐ Unspecified 1 ‐ Right 2 ‐ Le  

 1‐  Medias num 2 ‐ Pluera 4 ‐ Small intes ne 5 ‐ Large Intes ne & rectum 6 ‐ Retroperitoneum and peritoneum 7 ‐Liver and intrahepa c bile duct 

 0 ‐ Lung 

STOP

 3 ‐ Other/unspecified respiratory organs 8 ‐ Other/unspecified diges ve organs 

 0 ‐ Unspecified 9 ‐ Other 

C78.

Secondary & Unspecified Malignant Neoplasm of 

LYMPH NODES  0 ‐ Head, face, & neck 1‐  Intrathoracic  2 ‐ Intra‐abdominal  3 ‐ Axilla and upper limb  4 ‐ Inguinal and lower limb  5 ‐ Intrapelvic  8 ‐ Lymph nodes of mul ple regions 9 ‐ Unspecified 

C77.

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© Copyright 2015; Revised 9/24/15

SECONDARY & UNSPECIFIED SITES  

ACUTE EMBOLISM & THROMBOSIS OF DEEP VEINS OF LOWER EXTREMITY  0 ‐ Unspecified deep veins/        lower extremity 1 ‐ Femoral vein 2 ‐ Iliac vein 3 ‐ Popliteal vein 4 ‐ Tibial vein 9 ‐ Other specified Y ‐ Proximal lower extremity Z ‐ Distal lower extremity 

 1 ‐ Right  2 ‐ Le   3 ‐ Bilateral 9 ‐ Unspecified  

I82.4 PULMONARY  EMBOLISM W/O ACUTE COR PULMONALE  0 ‐ Sep c pulmonary embolism  2  ‐ Saddle embolus of pulmonary artery  9 ‐ Other  

I26.9

THROMBOTIC CONDITIONS 

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© Copyright 2015; Revised 9/24/15

DRUG-INDUCED PHENOMENON

D70.1 AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY

OTHER SECONDARY THROMBOCYTOPENIA

D69.59

* Due to drugs, EtOH, alloimmunization; NOT ITP

DRUG (OPIATE) INDUCED CONSTIPATION

K59.09

ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPY

D64.81

DRUG-INDUCED CUSHING'S SYNDROME

E24.2 DRUG-INDUCED ADRENOCORTICAL INSUFFICIENCY

E27.3

STOP 0 - With cholestasis 2 - With acute hepatitis

TOXIC LIVER DISEASE

0 - Without coma 1 -With coma

1 - With hepatic necrosis

This is for toxic effects due to drug; Does Not include ETOH

K71.

0 - Drug-induced 1 - Alcoholic 2 - Due to other toxic agents 9 - Unspecified (as used for AIDS)

Other & Unspecified POLYNEUROPATHIES

1 -Critical illness 2 - Radiation-induced 9 - Other

8 - Other specified

STOP

G62.

ORAL MUCOSITIS, ULCERATIVE

0 -Unspecified 1 - Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other

K12.3

POLYNEUROPATHY IN DISEASES CLASSIFIED ELSEWHERE (Includes myeloma induced neuropathy)

G63

DRUG-INDUCED PHENOMENON

DRUG (OPIATE) INDUCED CONSTIPATION

K59.09

AGRANULOCYTOSIS DUE TO NON-CHEMOTHERAPY DRUG

D70.2