Coding for Liver Cancer
For The Record
Vol. 18 No. 4 P. 41

Primary liver cancer occurs when cancerous cells begin to grow abnormally in the tissues of the liver. The number of cases diagnosed has increased significantly between 1975 and 1995 due to the increase in hepatitis B and C infection, the leading cause of liver cancer. Other causes include the following:

• cirrhosis;

• long-term exposure to aflatoxins;

• vinyl chloride and thorium dioxide (Thoratrast); and

• drinking water contaminated with arsenic.

Typically, cancer found in the liver has spread there from another part of the body. The cancer cells detach from the primary site (ie, the breast or lungs) and travel through the circulatory or lymphatic system to the liver. Metastasis to the liver is the second most common site for metastatic disease with lymph node metastasis being the first.

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.

Types of Liver Tumors
The following are types of primary liver cancer:

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

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

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

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

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.

Signs and Symptoms
The following common signs and symptoms may appear in a patient with liver cancer: loss of appetite; weight loss; right upper quadrant abdominal pain, which may extend into the back and right shoulder blade; nausea and vomiting; general weakness and fatigue; enlarged liver; ascites; and jaundice.

Diagnosis
Most types of liver cancer are not diagnosed early due to the fact that symptoms do not appear in the early stages and because liver cancers can grow quickly.

If liver cancer is suspected, the physician may perform blood tests, ultrasound, computed tomography (CT) scan, CT angiography, magnetic resonance imaging, liver scan, and liver biopsy. If the liver biopsy is done by a laparoscope, assign a code for the laparoscopy (54.21) and the closed liver biopsy (50.11). According to Faye Brown, “Although most biopsy codes have been revised to identify an endoscopic biopsy, a few codes still do not make this distinction.… If it is done by endoscopy, codes for both the endoscopic approach and the biopsy are assigned” (Faye Brown’s ICD-9-CM Coding Handbook, American Hospital Association, 2004, page 52).

If the physician performs a needle biopsy of the liver through a laparotomy, assign codes 54.11, Exploratory lapartotomy, 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 was with a needle despite the procedure being done through an open approach.

Staging
Staging determines the size and location of cancer and whether it has spread. The following is one staging method used to stage primary liver cancer in adults:

• localized resectable — tumor is confined to one lobe of the liver and can be completely removed surgically;

• localized unresectable — tumor is confined to one lobe of the liver but can’t be removed surgically;

• advanced — cancer has spread throughout the liver or other body parts such as bones or lungs; and

• recurrent — cancer has returned to the liver or another body part after it has been treated.

A common staging method for primary liver cancer in children includes the following:

• stage 1 — cancer can be removed surgically;

• stage 2 — cancer can be removed surgically, but microscopic amounts remain in the liver after surgery;

• stage 3 — some cancer may be surgically removed, but some will remain in lymph nodes or abdomen;

• stage 4 — cancer has spread to other body parts; and

• recurrent — cancer has returned to the liver or another body part after it has been treated.

Treatment
Treatment of liver cancer depends on the stage and type of cancer plus the patient’s age, overall health, and personal preferences. The goal of treatment is to eliminate the cancer completely. If this is not possible, the focus switches to preventing the cancer from growing or spreading. The available treatment options 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. Total hepatectomy (50.4) is 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, and eventually the cells die.

• Radiofrequency ablation (50.29) — 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.

• Cryosurgery/cryotherapy (50.20) — uses extreme cold to destroy cancer cells.

• Liver transplantation (50.59) — removes the diseased liver and replaces it 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 Health Information Systems (800-367-2447), a supplier of coding and classification systems to nearly 5,000 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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