Find comprehensive information on History of Colon Carcinoma, including clinical documentation requirements, ICD-10 coding (C18), medical coding guidelines, and healthcare best practices for diagnosis. Learn about staging, treatment options, and follow-up care related to a past diagnosis of colon cancer. This resource offers valuable insights for physicians, coders, and other healthcare professionals seeking accurate and up-to-date information on History of Colon Carcinoma.
Also known as
Personal history of malignant neoplasm of colon
History of colon cancer.
Personal history of malignant neoplasm of digestive organs
History of cancer in the digestive system.
Factors influencing health status and contact with health services
Relates to past medical history and health status.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the colon carcinoma currently present?
Yes
Is it primary?
No
Personal history documented?
When to use each related code
Description |
---|
Colon Carcinoma |
Colon Adenoma |
Colon Polyps |
Coding Z85.038 without specifying stage if known (e.g., in remission) impacts reimbursement and quality reporting.
Incorrectly coding active malignancy (C18.-) instead of history (Z85.038) leads to overreporting and inaccurate cancer registry data.
Vague documentation lacking details about remission status or recurrence makes accurate coding of Z85.038 difficult, affecting data integrity.
Patient presents with a history of colon carcinoma, diagnosed on [Date of Diagnosis] by [Diagnostic Method, e.g., colonoscopy with biopsy]. The primary tumor was located in the [Specific Location, e.g., sigmoid colon] and was staged as [Stage, e.g., T3N1M0] according to the AJCC TNM staging system. Histopathology revealed [Histological Type, e.g., adenocarcinoma, moderately differentiated]. Initial treatment included [Treatment Modality, e.g., surgical resection with hemicolectomy] performed on [Date of Procedure]. Surgical margins were [Margin Status, e.g., negative]. Lymph node involvement was noted with [Number] out of [Number] lymph nodes positive for malignancy. Adjuvant therapy consisted of [Adjuvant Therapy, e.g., FOLFOX chemotherapy regimen] completed on [Date of Completion]. Patient is currently under surveillance for recurrence with [Surveillance Modality, e.g., CEA levels, CT scans] performed every [Frequency, e.g., 3 months]. Current symptoms include [Current Symptoms, e.g., asymptomatic, mild abdominal discomfort, fatigue]. Physical exam findings are notable for [Physical Exam Findings, e.g., well-healed surgical scar, normal bowel sounds]. Assessment: History of colon cancer, stage [Stage], status post [Treatment Summary]. Plan: Continue surveillance per established guidelines. Address current symptoms as needed. Patient education provided regarding signs and symptoms of recurrence, importance of follow-up, and healthy lifestyle modifications including diet and exercise. ICD-10 code: Z85.038 (Personal history of malignant neoplasm of colon).