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October 10, 2011

Coding for Bladder Cancer
For The Record
Vol. 23 No. 18 P. 28

Bladder cancer is easier to treat if cases are diagnosed early,. However, if the cancer spreads beyond the bladder lining, it becomes more difficult to treat. Smoking is the single greatest risk factor for bladder cancer.

Bladder cancer does not typically produce signs and symptoms in the early stages. When symptoms do develop, they may include hematuria (urine may appear bright red, dark yellow, or a dark brown, or may appear normal with microscopic blood detected), frequent urination, painful urination, urinary tract infection, and abdominal or back pain.

Where the bladder cancer begins determines the type of cancer. Most bladder cancers are caused by transitional cell carcinoma, which begins in the cells that line the bladder walls. Another type is squamous cell carcinoma, which begins in thin, flat cells and is caused by infection and irritation. It may also be caused by adenocarcinoma, which begins in cells that make up mucus-secreting glands in the bladder.

Primary malignant bladder cancer is classified to ICD-9-CM category 188. The following are the fourth digits necessary to identify the specific site:

• 188.0, Trigone of urinary bladder;

• 188.1, Dome of urinary bladder;

• 188.2, Lateral wall of urinary bladder;

• 188.3, Anterior wall of urinary bladder;

• 188.4, Posterior wall of urinary bladder;

• 188.5, Bladder neck, including internal urethral orifice;

• 188.6, Ureteric orifice;

• 188.7, Urachus;

• 188.8, Other specified sites of bladder (includes malignant neoplasm of contiguous or overlapping sites of bladder whose point of origin cannot be determined); and

• 188.9, Bladder, part unspecified (includes bladder wall not otherwise specified).

Carcinoma in situ (233.7) remains confined to the bladder lining. Bladder cancer may grow into or through the bladder wall and eventually into nearby lymph nodes (196.2) or to adjacent organs such as the lungs (197.0), liver (197.7), or bones (198.5). If cancer originally develops elsewhere and metastasizes to the bladder, then assign code 198.1.

The physician will perform a complete physical exam, including an internal exam. Other possible tests may include the following:

• cystoscopy (insertion of scope into the bladder to view the cancer and possibly take a biopsy sample);

• ujrine cytology (checks for cancer cells but may miss low-grade cancers);

• intravenous pyelogram (views the kidney and lower urinary tract); and

• CT (views the urinary tract and surrounding tissue).

After bladder cancer is confirmed, additional tests may be ordered to determine whether the cancer has spread and/or metastasized. With the information obtained, the physician will stage the cancer as follows:

• Stage I: Cancer occurs in the bladder’s inner lining but hasn’t invaded the muscular bladder wall.

• Stage II: Cancer has invaded the bladder wall, but is still confined to the bladder

• Stage III: Cancer has spread through the bladder wall to the surrounding tissue. It may have also spread to the prostate in men or the uterus or vagina in women.

• Stage IV: Cancer has spread to the lymph nodes or other sites such as lungs, bones, or liver.

• Recurrent: Cancer has returned after having been treated. It may recur in the same place or in another part of the body.

Surgery is the best treatment option. The most common procedure used to treat early-stage cancer is transurethral resection of bladder tumor, which is classified to ICD-9-CM code 57.49. A cystoscope is inserted into the bladder through the urethra, and the cancer is removed with a small wire loop. The remaining cells are burned away by an electric current or a laser (fulguration).

Segmental cystectomy (57.6) may be performed for cancer that goes deeper into the tissue but is confined to one area of the bladder. Radical cystectomy (57.71) removes the entire bladder and nearby lymph nodes. In men, the prostate gland, seminal vesicles, and a portion of the vas deferens are also removed. In women, the ovaries, fallopian tubes, and part of the vagina are also removed.

According to coding directives, additional codes should be assigned for lymph node dissection (40.3, 40.5) and urinary diversion (56.51-56.79). A total cystectomy not documented as radical is classified to code 57.79.

Coding and sequencing for bladder 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-CM/PCS Coding for Bladder Cancer
Bladder cancer is classified to ICD-10-CM category C67. The fourth digit identifies the specific location of the cancer, similar to ICD-9-CM, as follows:

• C67.0, Malignant neoplasm of trigone of bladder;

• C67.1, Malignant neoplasm of dome of bladder;

• C67.2, Malignant neoplasm of lateral wall of bladder;

• C67.3, Malignant neoplasm of anterior wall of bladder;

• C67.4, Malignant neoplasm of posterior wall of bladder;

• C67.5, Malignant neoplasm of bladder neck including internal urethral orifice;

• C67.6, Malignant neoplasm of ureteric orifice;

• C67.7, Malignant neoplasm of urachus;

• C67.8, Malignant neoplasm of overlapping sites of bladder; and

• C67.9, Malignant neoplasm of bladder, unspecified.

As stated above, the most common procedure performed for bladder cancer in the early stages is transurethral resection of bladder tumor (TURBT). For ICD-10-PCS code assignment, refer to the root operation “excision” since only a portion of the body part (bladder) is removed. The approach is “via natural or artificial opening endoscopic” since the cystoscope is inserted into the urethra. Therefore, the ICD-10-PCS code for TURBT is 0TBB8ZZ. If a fulguration is also done, then also assign code 0T5B8ZZ using the root operation “destruction.”