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For other articles and previous issues click here. January 31, 2005 Coding
for Gastric Cancer Gastric cancer occurs when malignant cells form in the lining of the stomach. Typically, the cancer begins in the mucosal layer, which is the innermost layer of the stomach, and then spreads to the outer layers as it grows. Primary gastric malignancy is classified to ICD-9-CM category 151, Malignant neoplasm of stomach. The fourth digit identifies the site of the malignancy as follows: • 151.0, Cardia (opening of the stomach from the esophagus) • 151.1, Pylorus • 151.2, Pyloric antrum • 151.3, Fundus of stomach • 151.4, Body of stomach, also called corpus • 151.5, Lesser curvature of stomach • 151.6, Greater curvature of stomach • 151.8, Other specified sites of stomach, which includes anterior wall not elsewhere classified (NEC), posterior wall NEC, and contiguous or overlapping sites of stomach whose point of origin cannot be determined • 151.9, Stomach unspecified Code 151.8 is assigned when the point of origin cannot be determined because the neoplasm overlaps the boundaries of two or more contiguous sites and cannot be assigned to any other code within category 151. The majority of gastric cancer is caused by adenocarcinoma, which develops in the glandular tissues in the stomach lining. A code from category 151 will be assigned when a patient is diagnosed with adenocarcinoma of the stomach. Tumors that develop in the stomach’s lymphatic tissue are called lymphoma. Assign a code from categories 200-202 with a fifth digit of 3 if the patient is diagnosed with lymphoma of the stomach. When the tumor develops in the patient’s connective tissue such as muscle, fat, or blood vessel, it is called sarcoma. Sarcoma of the stomach is classified to code 171.5, Malignant neoplasm of connective and other soft tissue of abdomen. Benign neoplasm of the stomach is classified to code 211.1. As always, correct code assignment is based on physician documentation in the medical record. In the inpatient setting, if the physician does not confirm the findings in the pathology report in the body of the medical record, then the physician should be queried for clarification of the clinical significance of the findings before final code assignment can be made (AHA Coding Clinic for ICD-9-CM, 2004, first quarter, pages 20-21). Signs and Symptoms • Microscopic blood in stool • Indigestion and heartburn • Stomach discomfort/pain • Black, tarry stools • Hematemesis • Vomiting after meals • Weakness, fatigue • Weight loss Diagnosis • Fecal occult blood test to check for microscopic blood in stool • Esophagogastroduodenoscopy to see abnormalities in the upper gastrointestinal (GI) tract. A biopsy may also be performed during this procedure. • Barium swallow/upper GI series • Endoscopic ultrasound (endosonography) • Computed tomography scan • Magnetic resonance imaging • Laparoscopy • Chest x-ray • Positron emission tomography The patient’s prognosis depends on the stage and extent of the cancer. When found early, there is a good chance of recovery. However, this condition is often diagnosed after it has advanced. Staging • Stage 0 (carcinoma in situ [ICD-9-CM code 230.2]) — cancer is only found in the inside lining of the mucosal layer of the stomach wall • Stage 1A — cancer has gone completely through the mucosal layer • Stage 1B — cancer has gone completely through the mucosal layer and is in one to six lymph nodes near the tumor; or the cancer has gone to the muscularis (middle) layer of the stomach wall • Stage II — cancer has gone through the mucosal layer of stomach and is in seven to 15 lymph nodes near the tumor; or cancer has gone to the muscularis layer and is in one to six lymph nodes near the tumor; or the cancer has gone to the serosal (outermost) layer of the stomach but not to any lymph nodes • Stage IIIA — cancer has spread to the muscularis layer and is in seven to 15 lymph nodes near the tumor; or the cancer has spread to the serosal layer of the stomach and is in one to six lymph nodes near the tumor; or the cancer has spread to the organs next to the stomach but not to lymph nodes or other parts of the body • Stage IIIB — cancer has spread to the serosal layer and is in seven to 15 lymph nodes near the tumor • Stage IV — cancer has spread to organs next to the stomach and to at least one lymph node; or to more than 15 lymph nodes; or to other parts of the body • Recurrent cancer — cancer has recurred after it has been treated; the cancer may come back in the stomach or in other parts of the body such as in the liver or lymph nodes Treatment Treatment may include the following: • Surgery. Depending on the extent of cancer, the surgeon may choose to perform either a partial (subtotal) or total gastrectomy. Partial gastrectomy NEC is classified to code 43.89. The code assignment could change depending on whether an anastomosis was performed to the esophagus (43.5) or to the small intestine (43.6 or 43.7). Total gastrectomy is classified to code 43.99. • Chemotherapy • Radiation therapy • Biologic therapy, which is also called biotherapy or immunotherapy Coding and sequencing for gastric cancer are dependent upon 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, and Vicki Sippel, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. |
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