Coding for Colon Cancer
For The Record
Vol. 18 No. 5 P. 39

Colon cancer, the second-leading cause of cancer-related deaths in the United States, may begin as small, benign adenomatous polyps that become cancerous over time. Different types of colon polyps include the following:

• adenomas;

• hyperplastic polyps;

• inflammatory polyps;

• familial adenomatous polyposis, a rare hereditary disorder that causes hundreds of polyps to form in the lining of the colon, beginning in the teenage years (If left untreated, there is a high risk for the patient to develop colon cancer.); and

• hereditary nonpolyposis colorectal cancer, a hereditary disorder that causes an increased risk of developing colon cancer.

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

• hepatic flexure: 153.0;

• transverse colon: 153.1;

• descending colon: 153.2;

• sigmoid colon: 153.3;

• cecum: 153.4;

• appendix: 153.5;

• ascending colon: 153.6;

• splenic flexure: 153.7;

• other specified sites of large intestine (including malignant neoplasm of contiguous or overlapping sites of the colon in which point of origin cannot be determined): 153.8; and

• colon, unspecified: 153.9.

Metastasis to the colon is classified to code 197.5. If the rectum is included with the colon cancer, then assign code 154.0, malignant neoplasm of rectosigmoid junction.

Signs and Symptoms
The following are the common signs and symptoms for colon cancer:

• change in bowel habits;

• blood in stool;

• diarrhea, constipation, or feeling that the bowel does not empty completely;

• pencil-thin stools;

• persistent cramping;

• gas pains, bloating, or fullness;

• abdominal pain; and

• unexplained weight loss.

Symptoms may be caused by other conditions such as the following:

• inflammatory bowel disease (558.9);

• irritable bowel syndrome (564.1);

• diverticulosis (562.10 without mention of hemorrhage or 562.12 with hemorrhage); and

• diverticulitis (562.11 without mention of hemorrhage or 562.13 with hemorrhage).

Diagnosis
A physician may perform some of the following tests to diagnose colon cancer:

• 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; and

• virtual colonoscopy (88.01) — computerized tomography scan of colon.

Staging
The following are the major stages of colon cancer:

• stage 0: cancer has not grown beyond the inner layer (mucosa) of the colon; also called carcinoma in situ (230.3)

• stage 1: cancer has grown through the mucosa into the middle layer but hasn’t spread through the colon wall

• stage 2: the cancer has grown through the wall of the colon but hasn’t spread to regional lymph nodes

• stage 3: cancer has spread to any number of regional lymph nodes but not to other parts of the body

• stage 4: cancer has spread to distant sites such as liver, lung, or ovary; and

• recurrent: cancer has come back after treatment.

Treatment
The primary treatment for colon cancer is surgery to remove the cancer. How much colon is removed and other treatment depends on location, size, stage of cancer, and whether the cancer has spread. The surgeon will remove the part of the colon containing the cancer as well as a margin of normal tissue and nearby lymph nodes and usually tries reconnecting the colon (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 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.

Colostomy Closure
The colostomy is typically closed approximately two to three months after the main surgery. A patient admitted for a colostomy closure is assigned to code V55.3 as the principal diagnosis with a procedure code of 46.52. Closure of a colostomy involves minor trimming of the colon edges prior to anastomosis. Both the trimming and the anastomosis are included in the closure code. However, if further resection is performed, an additional code for the colectomy may be assigned (AHA Coding Clinic for ICD-9-CM, 1991, second quarter, page 16). Review the operative report for complete and accurate code assignment.

According to the Official ICD-9-CM Guidelines for Coding and Reporting, effective December 1, 2005, “The aftercare V code should not be used if treatment is directed at a current, acute disease or injury.” Code V55.3 is considered an aftercare V code.

Coding and sequencing for colon 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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