Find comprehensive information on documenting a history of rectal cancer. This resource covers clinical documentation requirements, ICD-10 codes (C20, C78.5), medical coding best practices for rectal cancer, past medical history of rectal adenocarcinoma, staging (TNM), tumor location, treatment history including surgery (APR, LAR), chemotherapy, and radiation therapy. Learn about follow-up care, surveillance colonoscopy guidelines, and coding for history of primary rectal cancer. Improve your healthcare documentation and ensure accurate medical coding for patients with a history of rectal neoplasm.
Also known as
Personal history of malignant neoplasm of rectum
Indicates a past diagnosis of rectal cancer, now resolved.
Malignant neoplasms of rectosigmoid junction, rectum
Classifies current rectal cancers and those of the rectosigmoid junction.
Personal history of malignant neoplasms
Broad category for all personal histories of cancer, including rectum.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the rectal cancer currently active?
Yes
Is there metastasis?
No
Patient in remission?
When to use each related code
| Description |
|---|
| Rectal Cancer |
| Anal Cancer |
| Rectosigmoid Cancer |
Coding history of rectal cancer without specifying stage (e.g., in situ, localized, regional, distant) impacts reimbursement and quality reporting.
Incorrectly coding active vs. history of rectal cancer when patient is receiving ongoing surveillance or treatment for recurrence.
Miscoding rectal cancer as primary when it metastasized from another primary site leads to inaccurate cancer registry data and analytics.
Patient presents with a history of rectal cancer, diagnosed on [Date of Diagnosis]. The primary tumor was located in the [Specific Location of Tumor, e.g., rectum, rectosigmoid junction] and was staged as [Stage, e.g., TNM stage, AJCC stage] at the time of diagnosis. Initial treatment consisted of [Treatment Modalities, e.g., surgery, radiation therapy, chemotherapy, neoadjuvant therapy, adjuvant therapy]. Surgical details, if applicable, include [Surgical Procedure, e.g., low anterior resection, abdominoperineal resection] with [Margin Status, e.g., negative margins, positive margins, distance to closest margin]. Pathology revealed [Histological Type, e.g., adenocarcinoma, mucinous adenocarcinoma] with [Grade, e.g., well-differentiated, moderately differentiated, poorly differentiated]. Lymph node involvement was [Number of Positive Lymph Nodes/Total Number of Lymph Nodes Examined]. The patient [Currently Receiving/Completed] [Adjuvant Therapy Details, e.g., chemotherapy regimen, radiation therapy details]. Current surveillance includes [Surveillance Modalities, e.g., physical exam, CEA levels, CT scans, colonoscopy] with a frequency of [Frequency of Surveillance]. Patient reports [Symptoms, e.g., asymptomatic, rectal bleeding, changes in bowel habits, abdominal pain, tenesmus]. Physical exam findings include [Physical Exam Findings, e.g., normal rectal exam, palpable mass, tenderness]. Assessment includes history of rectal cancer with [Current Status, e.g., no evidence of disease, recurrent disease, metastatic disease] and [Current symptoms, e.g., ongoing symptoms, resolved symptoms]. Plan includes [Plan of Care, e.g., continued surveillance, further imaging, referral to oncology, palliative care].