What should be assigned as the principal diagnosis when surgical removal of a neoplasm is followed by adjunct treatment?

When determining the principal diagnosis following the surgical removal of a neoplasm that is subsequently treated with adjunct therapy, the correct approach is to assign the code for the neoplasm. This coding strategy is grounded in the understanding that the neoplasm itself is the main reason for the surgical intervention.

In such scenarios, the neoplasm is the underlying condition that necessitated the surgery, and the surgery is considered a definitive treatment of that specific neoplasm. The adjunct treatment, while important, does not change the principal focus of care from the neoplasm itself. As per coding guidelines, the principal diagnosis is typically the condition that is chiefly responsible for the patient’s admission or the primary reason for the procedure performed.

Other options might suggest coding for treatments or complications, but these would not appropriately reflect the primary reason for the encounter which, in this case, remains the neoplasm that was surgically removed. The coding guidelines emphasize the significance of capturing the primary diagnosis to communicate effectively the clinical intent and the complexity of the patient's condition to insurers and maintain accurate patient records.