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AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 1; Ask the Editor

Admission for Consolidation Chemotherapy with Bone Marrow Biopsy

A patient with central nervous system 1a, B-cell acute lymphoblastic leukemia (B-ALL) is admitted for intrathecal consolidation chemotherapy. Immediately following chemotherapy, per protocol, an end of induction bone marrow biopsy is performed to evaluate the effectiveness of prior therapy and to determine whether the leukemia is in remission. The Official Guidelines for Coding and Reporting (I.C.2.a.) states, “When treatment is directed at a malignancy, the malignancy is sequenced as the principal diagnosis, except when the admission is solely for chemotherapy.” In this case, the provider clearly documents the reason for admission is the administration of chemotherapy and the bone marrow biopsy was part of the treatment protocol. When a patient is admitted for chemotherapy but also has a diagnostic test such as a biopsy, is the neoplasm assigned as the principal diagnosis instead of code Z51.11, Encounter for antineoplastic chemotherapy? What is the principal diagnosis in this case? ...

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