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Q: Can someone have a metastatic tumor without having a primary cancer?

That’s goes back to the question, metastatic breast, that’s 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 they’ll look under the microscope and they’ll 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 haven’t 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 haven’t determined where. What do you do? So that’s a metastatic breast. They know because they looked at the cells, Pathology tells them it’s still a secondary cancer.

Metastatic Tumor Coding – Primary vs. Secondary Cancer Video

However, in some patients – this is underlined that’s 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. That’s 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 you’re 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 don’t let you do that with other diagnoses.

But with cancer, when I worked for UHC, they did say that’s the only diagnosis that you can use other encounters to determine the encounter that you’re 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 person’s chart and see if you can get to a higher specificity, but with just plain metastatic breast, I would say that’s secondary.

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Metastatic Tumor Coding - Primary vs. Secondary Cancer

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