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February 9, 2004

Coding for Colorectal Cancer
Vol. 16 No. 3 p. 41

Colorectal cancer includes cancerous growths of both the large intestine and rectum. Nearly one-half of all colon cancers occur in the rectosigmoid area. Colorectal cancer, which is one of the leading causes of cancer-related deaths in the United States, may begin as small benign polyps that turn cancerous. Polyps may be asymptomatic and are only detectable during screening tests. Colorectal cancer may also be caused from villous adenomas and adenocarcinomas.

Cancer of the rectum is classified to ICD-9-CM code 154.1. If the cancer is of the rectosigmoid junction, assign code 154.0, which includes cancer of the colon and rectum. Cancer of the colon is classified to category 153. The fourth digit subcategory will identify the specific location of the colon cancer. If the tumor is benign, assign code 211.3 for the colon or 211.4 for the rectum.

Signs and Symptoms

In the early stages, a patient may not have any symptoms. As symptoms develop, they will vary depending on the size and location of the tumor. Common signs and symptoms include the following:
• diarrhea or constipation;
• change in bowel habits;
• narrow stools;
• blood in the stool—either bright red or very dark;
• abdominal discomfort such as cramps, gas, and pain;
• feeling that the bowel didn’t empty completely; and
• unexplained weight loss.

There are conditions other than cancer that may also cause the above symptoms, such as inflammatory bowel disease (558.9), irritable bowel syndrome (564.1), diverticulosis (562.10), and diverticulitis (562.11).

Screening

The American Cancer Society recommends colorectal screenings beginning at age 50 and more frequent or earlier screenings if you have other risk factors such as a family history of the disease. If a patient is seen for a screening colonoscopy or sigmoidoscopy, assign code V76.51 as the principal diagnosis. A screening test is looking for a disease in a seemingly well patient (eg, no signs or symptoms of the condition are present) so that detection and treatment can begin early in patients who test positive. Code V76.51 is used as the principal diagnosis even if a condition is identified during the screening test. A code for the condition may be sequenced as a secondary diagnosis (AHA Coding Clinic for ICD-9-CM, 2001, fourth quarter, pages 55-56).

Diagnosis

Common diagnostic procedures include the following:
• Digital rectal exam — detects polyps in lower rectum
• Fecal occult blood test — detects microscopic blood in stool. A positive result does not confirm cancer since not all cancers bleed. In addition, other gastrointestinal (GI) conditions do cause GI hemorrhage. Therefore, further testing is necessary to confirm the appropriate diagnosis.
• Flexible sigmoidoscopy — detects polyps in rectum and sigmoid. The rectum is approximately 8 inches to 10 inches long, where the sigmoid is approximately 2 feet long.
• Barium enema — barium dye is infected in the bowel in an enema form. In a double contrast barium enema, air is also added to the bowel. The dye outlines the colon and rectum, which is visible in an x-ray.
• Colonoscopy (45.23) — detects polyps in the colon and rectum. The physician may take a biopsy during the colonoscopy (45.25) or remove the polyps (45.42).
• Virtual colonoscopy (88.01) — uses computerized tomography scan to view the colon. The x-ray is then rotated to view every part of the colon without actually going inside the colon.

Stages

The following are the different stages of colorectal cancer:
• Stage 0 — tumor hasn’t grown beyond the inner layer of the colon or rectum. It is also called carcinoma in situ.
• Stage I (Dukes A) — tumor has grown through the mucosa (inner, second, and third layers of colon wall)
• Stage II (Dukes B) — tumor has grown through colon wall
• Stage III (Dukes C) — tumor has spread to nearby lymph nodes
• Stage IV (Dukes D) — tumor has spread to distant sites such as other organs (liver, lung)
• Recurrent — cancer has returned after treatment

Treatment

Surgery is the primary treatment for colorectal cancer. How much colon is removed and other treatment depends on location, size, stage of cancer, and whether or not the cancer has spread. 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 (45.92-45.94).

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 was performed. There is a procedure code assignment that includes an anterior resection of the rectum with synchronous colostomy (48.62).

Chemotherapy and radiation therapy may be used in combination with the surgical removal of the colorectal cancer. However, they may also be used alone to destroy cancer cells, control tumor growth, or relieve symptoms of colorectal cancer.

Coding and sequencing for colorectal 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, 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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