June 6, 2011

Coding for Liver Cancer
For The Record
Vol. 23 No. 11 P. 27

Liver cancer, also documented as primary liver cancer or hepatoma, is usually caused by cirrhosis or scarring of the liver, which may be due to alcohol abuse, autoimmune diseases of the liver, hepatitis B or C, or hemochromatosis.

Typically, cancer found in the liver has metastasized there from another part of the body. The cancer cells detach from the primary site, such as the breast or the lungs, and travel through the circulatory or lymphatic system to the liver. The liver is the second most common site for metastatic disease, with lymph nodes being the first.

Primary Liver Cancer
The following are types of primary liver cancer:

• Hepatocellular carcinoma (155.0), the most common form, starts in the hepatocytes.

• Cholangiocarcinoma (155.1) begins in small bile ducts in the liver. Cholangiocarcinoma combined with hepatocellular carcinoma is classified to code 155.0.

• Hepatoblastoma (155.0) may be caused by an abnormal gene. This type affects children younger than the age of 4.

• Angiosarcoma (155.0) or hemangiosarcoma (155.0) begins in the blood vessels of the liver.

Benign Liver Tumors
The following are types of benign liver tumors:

• Hemangioma (228.04) most commonly affects the liver’s blood vessels.

• Hepatic adenoma (211.5) originates in hepatocytes and may be caused by birth control pills.

• Focal nodular hyperplasia is a combination of several types of cells.

ICD-9-CM Code Assignment
Primary liver cancer is classified to ICD-9-CM code 155.0. Secondary liver cancer, also called metastasis to the liver, is classified to code 197.7. If liver cancer is documented with no further specification stating primary or secondary, assign code 155.2. It is appropriate to query the physician for clarification if the cancer is not specified as primary or metastatic. Benign neoplasm of the liver is assigned to code 211.5.

Signs and Symptoms
Common signs and symptoms that may appear in a patient with liver cancer are a loss of appetite, weight loss, right upper quadrant abdominal pain (which may extend into the back and right shoulder blade), bleeding or bruising that occurs easily, nausea and vomiting, general weakness and fatigue, an enlarged liver, ascites, or jaundice.

Diagnosis
Most types of liver cancer are not diagnosed early since symptoms do not appear in the early stages and because liver cancers can grow quickly. If liver cancer is suspected, the physician may perform one or more diagnostic tests, including abdominal ultrasound, an abdominal CT scan, CT angiography, an MRI, a liver scan, liver enzyme testing (liver function tests), serum alpha fetoprotein testing, or a liver biopsy.

If the liver biopsy is done by a laparoscope, assign code 50.14. If the physician performs a needle biopsy of the liver through a laparotomy, assign codes 54.11, Exploratory laparotomy, and 50.11, Closed liver biopsy (AHA Coding Clinic for ICD-9-CM, 1988, fourth quarter, page 12). The closed biopsy code will be assigned because the biopsy technique used to obtain the tissue sample involved a needle despite the procedure being done through an open approach. Open or wedge biopsy is classified to code 50.12. Transjugular or transvenous liver biopsy is assigned to code 50.13.

Staging
Staging determines the size and the location of cancer and whether it has spread. A common staging method for primary liver cancer includes the following:

• Stage 1: a single tumor confined to the liver;

• Stage 2: a single tumor invading nearby blood vessels or multiple small tumors in the liver;

• Stage 3: several larger tumors in the liver or one large tumor invading the liver’s main veins or nearby structures, such as the gallbladder;

• Stage 4: cancer has spread to other parts of the body; or

• Recurrent: cancer has returned to the liver or another part of the body after treatment.

Treatment
The treatment for liver cancer depends on the stage and the type of cancer plus a patient’s age, overall health, and personal preferences. The goal of treatment is to eliminate the cancer completely, especially small or slow-growing tumors, if they are diagnosed early. However, liver cancer is rarely diagnosed in the early stages. If complete removal of the tumor(s) is not possible, the focus switches to preventing the cancer from growing or spreading. The treatment options available include the following:

• Surgery: partial hepatectomy (50.22), which may also be documented as wedge resection of liver; lobectomy of liver (50.3), which is the complete removal of a lobe of the liver; or total hepatectomy (50.4), the complete removal of the liver.

• Radiation therapy.

• Chemotherapy.

• Alcohol injection (50.94): Pure alcohol is injected directly into tumors, which will dry out the cells in the tumor so the cells eventually die.

• Radio-frequency ablation: An electric current in the radio-frequency range is used to destroy malignant cells. Thin needles are inserted into the tumor and heated with an electric current. Open ablation of the liver is classified to code 50.23. Code 50.24 identifies percutaneous ablation of the liver. Code 50.25 is for laparoscopic ablation of the liver, and other and unspecified ablation of the liver goes to 50.26.

• Cryosurgery/cryotherapy (50.29): Extreme cold is used to destroy cancer cells. If this procedure is done laparoscopically, assign code 50.25.

• Liver transplantation (50.59): The diseased liver is removed and replaced with a healthy donated organ. This procedure is rarely used for patients with liver cancer because, in most cases, the cancer recurs outside the liver after the transplant.

Coding and sequencing for liver cancer are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

Coding for Liver Cancer in ICD-10-CM
As in ICD-9-CM, the neoplasm table should be referenced first when classifying neoplastic conditions. In ICD-10-CM, the neoplasm table is located after the Alphabetic Index. If the histological term is documented, then that term should be referenced first in the index so the correct column in the neoplasm table is used when finding the specific code.

Several carcinoma types are specified in ICD-10-CM, which ICD-9-CM did not identify with separate codes. For malignant neoplasm of liver and intrahepatic bile duct, the following codes are available:

• C22.0, Liver cell carcinoma (including hepatocellular carcinoma and hepatoma);

• C22.1, Intrahepatic bile duct carcinoma (including cholangiocarcinoma);

• C22.2, Hepatoblastoma;

• C22.3, Angiosarcoma (including Kupffer cell sarcoma);

• C22.4, Other sarcomas of liver;

• C22.7, Other specified carcinomas of liver;

• C22.8, Malignant neoplasm of liver, primary, unspecified as to type; and

• C22.9, Malignant neoplasm of liver, not specified as primary or secondary.

— Audrey Howard