What is the first step when coding neoplasms if no primary site exists?

When coding neoplasms in situations where no primary site exists, the first step is to utilize the neoplasm table. This table is an essential resource that provides guidance on how to code various types of neoplasms, including benign, malignant, and in situ tumors. By consulting the neoplasm table, coders can systematically identify the appropriate codes based on the characteristics of the neoplasm, even when a primary site is not clearly defined.

Using the neoplasm table allows coders to categorize the neoplasm accurately, ensuring that the specific type of tumor is designated correctly, which is crucial for accurate medical record documentation and billing. This step typically precedes making assumptions about the neoplasm's nature, such as whether it is metastatic, or checking for other possible cancer types. It also sets the stage for determining whether further documentation is needed.

Overall, employing the neoplasm table for initial coding provides a structured approach to ensure that coding is performed based on established guidelines and terminologies, thereby improving the accuracy and consistency of coding practices in neoplasm documentation.