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July 30, 2012

Coding for Colon and Rectal Cancer
For The Record
Vol. 24 No. 14 P. 26

Colon cancer occurs in the large intestine or colon, which is the lower part of the digestive system. Rectal cancer occurs in the last several inches of the colon. Collectively, they may be referred to as colorectal cancer. The majority of colon cancer cases may begin as small, benign adenomatous polyps. Over time, the polyps become cancerous. Different types of colon polyps include adenomas; hyperplastic polyps; inflammatory polyps; familial adenomatous polyposis, a rare hereditary disorder that causes hundreds of polyps in the lining of the colon beginning in the teenage years (If left untreated, there is a high risk of developing colon cancer.); and hereditary nonpolyposis colorectal cancer.

Benign polyps of the colon are classified to ICD-9-CM code 211.3, Benign neoplasm of colon. Code 211.4 is assigned for benign polyps of the rectum or anal canal. Malignant neoplasm of colon is assigned to category 153. The fourth digit identifies the location of the neoplasm in the colon as follows:

• 153.0, Hepatic flexure;

• 153.1, Transverse colon;

• 153.2, Descending colon;

• 153.3, Sigmoid colon;

• 153.4, Cecum;

• 153.5, Appendix;

• 153.6, Ascending colon;

• 153.7, Splenic flexure;

• 153.8, Other specified sites of large intestine—includes malignant neoplasm of contiguous or overlapping sites of colon whose point of origin cannot be determined; and

• 153.9, Colon, unspecified.

Category 154 is assigned for malignant neoplasm of rectum, rectosigmoid junction, and anus, with the fourth digit identifying the specific location as follows:

• 154.0, Rectosigmoid junction includes colon with rectum and rectosigmoid;

• 154.1, Rectum includes rectal ampulla;

• 154.2, Anal canal includes anal sphincter;

• 154.3, Anus, unspecified; and

• 154.8, Other—includes malignant neoplasm of contiguous or overlapping sites of rectum, rectosigmoid junction, and anus whose point of origin cannot be determined.

If the rectum is included with the colon cancer, then assign code 154.0, Malignant neoplasm of rectosigmoid junction. Metastasis to the colon or rectum is classified to code 197.5. Carcinoma of the colon is assigned to code 230.3 while carcinoma of the rectum goes to 230.4.

Patients may not experience any symptoms of early-stage cancer. When signs and symptoms do appear, they may vary depending on the location of the cancer and may include changes in bowel habits, including diarrhea or constipation, or changes in the consistency of the stool; blood in the stool or rectal bleeding; feeling that the bowel does not empty completely; pencil-thin stools; persistent cramping, gas, or abdominal pain; and unexplained weight loss.

Symptoms may be caused by other conditions such as inflammatory bowel disease (558.9), irritable bowel syndrome (564.1), diverticulosis (562.10 without mention of hemorrhage or 562.12 with hemorrhage), or diverticulitis (562.11 without mention of hemorrhage or 562.13 with hemorrhage).

To diagnose colon cancer, a physician may perform a digital rectal exam, fecal occult blood test, flexible sigmoidoscopy, barium enema, colonoscopy (45.23)—the physician may take a biopsy (45.25) or polypectomy (45.42) through the colonoscope, or virtual colonoscopy (88.01), which is a CT scan of the colon.

The primary treatment for colon cancer is surgery to remove the cancer. How much of the colon is removed and other treatment depends on the location, size, and stage of cancer. The surgeon will remove the part of the colon that contains the cancer as well as a margin of normal tissue and nearby lymph nodes and usually tries to reconnect the colon together (anastomosis). Do not assign an additional procedure code for an end-to-end anastomosis. If the anastomosis is anything other than end to end—such as side to side, then assign an additional procedure code for the anastomosis (45.92 to 45.94).

If the surgeon can’t perform the anastomosis, then a permanent or temporary colostomy will be done. Assign an additional procedure code for the colostomy performed unless an anterior resection of the rectum or abdominoperineal resection of rectum was performed. Codes 48.5 and 48.62 include a synchronous colostomy.

Chemotherapy and radiation therapy may be used in combination with the surgical removal of the colon cancer.

Coding and sequencing for colon and rectal 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.


ICD-10-PCS Coding for Colon Resection
When a patient is admitted for colon resection, the root operation in ICD-10-PCS is typically going to be either an excision, or the cutting out or off, without replacement, of a portion of a body part, or a resection, or the cutting out or off, without replacement, of all of a body part.

The difference between these two definitions is the “portion” vs. “all” of a body part. What constitutes a body part in ICD-10-PCS depends on the body system. For the gastrointestinal system, the following body parts are available for the large intestine:

• large intestine (E);

• large intestine, right (F);

• large intestine, left (G);

• cecum (H);

• appendix (J);

• ascending colon (K);

• transverse colon (L);

• descending colon (M);

• sigmoid colon (N);

• rectum (P);

• anus (Q); and

• anal sphincter (R).

If all of one of the above body parts were removed, then the root operation should be resection. If only a portion of one of the above parts were removed, then it would be considered an excision.

The approach choices for the resection root operations include the following:

• open (0);

• percutaneous endoscopic (4);

• via natural or artificial opening (7); and

• via natural or artificial opening endoscopic (8).

The approaches for excision include the above and also include percutaneous (3) and external (X).