Find comprehensive information on rectal cancer diagnosis including ICD-10 codes C20 and C19-C21, clinical documentation requirements, staging (TNM, AJCC), treatment options, and pathology reports. Learn about relevant healthcare resources for patients and medical professionals, covering symptoms, screening (colonoscopy, biopsy), diagnosis, and management of rectal adenocarcinoma and other rectal malignancies. Explore reliable sources for medical coding best practices related to rectal cancer for accurate billing and reimbursement.
Also known as
Malignant neoplasm of rectum
Cancer originating in the rectum.
Secondary malignant neoplasms
Cancer that has spread to the rectum from another site.
Personal history of malignant neoplasm
History of rectal cancer, now in remission or cured.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the rectal cancer confirmed?
Yes
Is it in situ?
No
Do not code for rectal cancer. Code signs/symptoms or suspected diagnosis.
When to use each related code
| Description |
|---|
| Rectal Cancer |
| Anal Cancer |
| Rectosigmoid Junction Cancer |
Missing or incorrect laterality (right, left, overlapping) for rectal cancer impacts staging and treatment planning, leading to inaccurate reimbursement.
Discrepancy between clinical documentation and pathology report for histology code can affect coding accuracy and cancer registry data.
Insufficient documentation of TNM stage (tumor, node, metastasis) can lead to incorrect coding, impacting quality reporting and reimbursement.
Patient presents with complaints consistent with rectal cancer symptoms, including rectal bleeding, altered bowel habits (such as constipation, diarrhea, or tenesmus), abdominal pain, and unexplained weight loss. Physical examination may reveal a palpable rectal mass. Digital rectal examination findings are documented. The patient's medical history, including family history of colorectal cancer and relevant risk factors such as inflammatory bowel disease (IBD) or Lynch syndrome, is reviewed. Diagnostic workup includes colonoscopy with biopsy, which confirmed the diagnosis of rectal cancer. Pathology report details tumor location, size, grade, and differentiation. Staging workup, including pelvic MRI and CT scan of the chest, abdomen, and pelvis, is performed to assess for local and distant metastasis. Carcinoembryonic antigen (CEA) levels are obtained. The patient's clinical stage (TNM staging) is determined based on these findings. Treatment plan is discussed with the patient and may include surgery (e.g., low anterior resection, abdominoperineal resection), radiation therapy (neoadjuvant, adjuvant, or palliative), chemotherapy (neoadjuvant, adjuvant, or palliative), and targeted therapy. Patient education regarding treatment options, potential side effects, and follow-up care is provided. Referral to oncology, radiation oncology, andor colorectal surgery is made. Plan for ongoing surveillance and monitoring is established.