Find comprehensive information on esophageal cancer history including staging, TNM classification, ICD-10 CM codes (C15), clinical documentation requirements, pathology reports, endoscopic findings, Barrett's esophagus, risk factors, symptoms, and treatment options. Learn about diagnostic procedures for esophageal adenocarcinoma and squamous cell carcinoma, relevant medical coding guidelines, and best practices for healthcare professionals. This resource provides valuable insights for physicians, coders, and other healthcare providers involved in the diagnosis and management of esophageal cancer.
Also known as
Personal history of malignant neoplasm of esophagus
Indicates a past diagnosis of esophageal cancer.
Malignant neoplasms of esophagus
Includes codes for current esophageal cancers, helpful for specifying the type.
Factors influencing health status and contact with health services
Broad category encompassing personal history of various conditions, including cancer.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the esophageal cancer currently active?
Yes
Is there metastasis?
No
Is the patient in remission?
Using Z85.890 (personal history of malignant neoplasm of other specified sites) instead of Z85.828 (personal history of malignant neoplasm of esophagus) when documentation supports the specific site.
Coding active esophageal cancer (C15.x) when the documentation clearly indicates a history of cancer, not current disease, leading to overcoding and inflated severity.
Insufficient documentation to differentiate between history of invasive esophageal cancer and carcinoma in situ, impacting accurate code assignment (Z85.828 vs. Z85.821).
Patient presents with a history of esophageal cancer, status post esophagectomy performed on [Date of Surgery]. The patient reports [Current symptoms, e.g., dysphagia, odynophagia, reflux, weight loss, or asymptomatic]. Review of systems reveals [Pertinent positive and negative findings related to esophageal cancer and its treatment, e.g., changes in bowel habits, cough, hoarseness, chest pain, or fatigue]. Physical examination reveals [Objective findings, e.g., abdominal surgical scar, palpable masses, or lymphadenopathy]. Current medications include [List all medications]. Allergies include [List all allergies]. Surgical history is significant for esophagectomy with [Surgical technique, e.g., Ivor Lewis or transhiatal esophagectomy] for [Histological subtype of esophageal cancer, e.g., squamous cell carcinoma or adenocarcinoma] staged as [Tumor Node Metastasis (TNM) stage at diagnosis]. Prior treatment included [Neoadjuvant or adjuvant therapy details, e.g., chemotherapy, radiation therapy, or chemoradiation]. Patient is being monitored for recurrence with [Surveillance plan, e.g., imaging studies, endoscopy, or tumor markers]. Assessment: History of esophageal cancer. Plan: [Follow-up plan, e.g., continue surveillance, address current symptoms, referral to oncology, or nutritional counseling]. Differential diagnoses at initial presentation included GERD, achalasia, esophageal stricture, and esophageal spasm. ICD-10 code: Z85.820 (Personal history of malignant neoplasm of esophagus). Emphasis on quality of life and symptom management continues.