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September 29, 2008

Coding for Liver Cancer
For The Record
Vol. 20 No. 20 P. 42

Primary liver cancer occurs when cancerous cells grow abnormally in liver tissues. Some common causes include hepatitis B and C; 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 from another part of the body. The cancer cells detach from the primary site and travel through the circulatory or lymphatic system to the liver. Metastasis to the liver is the second most common site for metastatic disease.
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. Benign neoplasm of the liver is assigned to code 211.5.

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. When combined with hepatocellular carcinoma, it is classified to code 155.0.

• Hepatoblastoma (155.0) may be caused by an abnormal gene and affects children younger than the age of 4.

• Angiosarcoma (155.0) or hemangiosarcoma (155.0) begin 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
Common signs and symptoms of liver cancer include 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; an enlarged liver; ascites; and jaundice.

Most types of liver cancer are not diagnosed early because they can grow quickly. If liver cancer is suspected, the physician may perform blood tests, an ultrasound, CT or CT angiography, MRI, or a liver scan.

A liver biopsy can also be performed. If it’s done by a laparoscope, assign code 50.14. If the physician performs a needle biopsy through a laparotomy, assign codes 54.11, Exploratory laparotomy, and 50.11, Closed liver biopsy (AHA Coding Clinic for ICD-9-CM, 1988, fourth quarter, page 12). The closed biopsy code is assigned because the biopsy technique uses a needle even though the procedure was done through an open approach. Open or wedge biopsy is classified to code 50.12.

Liver cancer treatment depends on the stage and type of cancer plus the patient’s age, overall health, and personal preferences. The treatment goal is to eliminate the cancer. If impossible, the focus switches to preventing the cancer from growing or spreading. Possible 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, eventually killing them.

• Radiofrequency ablation (50.29) — Electric current in the radiofrequency range destroys malignant cells. Thin needles are inserted into the tumor and heated with an electric current. If this procedure is done laparoscopically, assign code 50.25.

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

• Liver transplantation (50.59) — 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 Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 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.