Find information on documenting and coding a personal history of colon cancer. Learn about the correct medical coding guidelines, including ICD-10 codes Z85.038 and Z86.010, for personal history of malignant neoplasm of colon and family history of colon cancer respectively. This resource offers guidance for healthcare professionals on accurate clinical documentation of past colon cancer, including staging, treatment history, and surveillance recommendations, essential for patient care and medical billing. Explore best practices for capturing complete patient medical history related to colon cancer in electronic health records and other healthcare documentation systems.
Also known as
Personal history of malignant neoplasm of colon
Indicates a past diagnosis of colon cancer.
Personal history of malignant neoplasm of digestive organs
History of cancer in digestive organs, including colon.
Factors influencing health status and contact with health services
Encompasses personal history of various conditions, including cancers.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the colon cancer currently active?
Yes
Code the active malignancy (e.g., C18.x). Do NOT use Z85.038.
No
Is patient currently in remission?
When to use each related code
| Description |
|---|
| Personal history of colon cancer |
| History of colon polyps |
| Family history of colon cancer |
Incorrect sequencing of active colon cancer vs. history of colon cancer codes (e.g., C18.- vs. Z85.038) can lead to claim denials.
Lack of documentation specifying type of colon cancer (e.g., adenocarcinoma) or laterality may impact coding accuracy for Z85.038.
Missing or inaccurate documentation of the initial colon cancer diagnosis date can affect treatment planning and coding accuracy.
Q: What are the most effective surveillance strategies for patients with a personal history of colon cancer, considering recurrence risk stratification and current guidelines?
A: Recurrence risk stratification after colon cancer resection is crucial for determining appropriate surveillance strategies. Factors such as TNM stage, lymphovascular invasion, perineural invasion, tumor grade, and MSI status inform the intensity of surveillance. Current guidelines, including those from the NCCN, recommend a combination of physical exams, CEA monitoring, colonoscopy, and CT imaging, with frequency and modality tailored to individual risk. For example, high-risk patients (stage II with high-risk features or stage III) require more intensive surveillance than lower-risk patients. Explore how incorporating molecular profiling can enhance risk stratification and personalize surveillance protocols for optimal patient outcomes. Consider implementing risk-adapted surveillance schedules based on these guidelines to effectively detect recurrence early.
Q: How can I differentiate between post-surgical changes and local recurrence of colon cancer on CT imaging in a patient with a history of colon resection?
A: Differentiating post-surgical changes from local recurrence on CT imaging can be challenging. Inflammatory changes, fibrosis, and the presence of surgical clips can mimic true recurrence. Careful evaluation of imaging features, such as nodular enhancement, irregular margins, and growth over time, are essential. Comparison with prior imaging is crucial for accurate interpretation. If uncertainty remains, consider obtaining dedicated pelvic MRI or utilizing PET/CT for improved tissue characterization. Furthermore, correlation with clinical findings, including CEA levels and physical examination, can aid in making the correct diagnosis. Learn more about emerging imaging techniques and their potential role in improving the accuracy of local recurrence detection.
Patient presents with a personal history of colon cancer. Initial diagnosis of colon cancer (ICD-10 C18) was made on [Date of Diagnosis] and confirmed by [Diagnostic Method, e.g., colonoscopy with biopsy]. The primary tumor site 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]. The patient underwent [Treatment Received, e.g., surgical resection, chemotherapy regimen name and dates, radiation therapy details] as primary treatment. Current surveillance includes [Current Surveillance Plan, e.g., colonoscopy every [Frequency], CEA levels every [Frequency]]. Patient reports [Current Symptoms or Status, e.g., being asymptomatic, experiencing specific symptoms like abdominal pain, changes in bowel habits]. Physical examination reveals [Relevant Physical Exam Findings, e.g., normal abdominal examination, presence of surgical scars]. Assessment: History of colon cancer. Plan: Continue current surveillance plan. Address any current symptoms as needed. Educate patient on importance of ongoing follow-up and potential long-term effects of colon cancer treatment. Genetic counseling may be considered based on family history and tumor characteristics. Refer to oncology as needed.