February 4 , 2008

Coding for Bladder Cancer
For The Record
Vol. 20 No. 3 P. 26

Bladder cancer begins in the bladder lining. If it spreads beyond the bladder lining, it becomes more difficult to treat. Smoking is the single greatest risk factor for bladder cancer. According to the National Cancer Institute, there were 67,160 new cases of bladder cancer in 2007 and 13,750 bladder cancer-related deaths.

Types of Bladder Cancer
Most bladder cancers are caused by transitional cell carcinoma. Transitional cell carcinoma of the bladder begins in the cells that line the bladder walls.

Another type of bladder cancer is squamous cell carcinoma, which begins in thin, flat cells. It may also be caused by adenocarcinoma, which begins in cells that make and release mucus and other fluids.

Primary malignant bladder cancer is classified to ICD-9-CM category 188. The following are the fourth digits necessary to identify the specific site of the cancer in the bladder:

• 188.1, Dome of urinary bladder;

• 188.2, Lateral wall of urinary bladder;

• 188.3, Anterior wall of urinary bladder;

• 188.4, Posterior wall of urinary bladder;

• 188.5, Bladder neck;

• 188.6, Ureteric orifice;

• 188.7, Urachus;

• 188.8, Other specified sites of bladder—includes malignant neoplasm of contiguous or overlapping sites of bladder whose point of origin cannot be determined; and

• 188.9, Bladder, part unspecified.

Carcinoma in situ (233.7) is cancer that remains confined to the bladder lining. Bladder cancer may grow into or through the bladder wall and eventually into nearby lymph nodes (196.2) or to adjacent organs such as the lungs (197.0), liver (197.7), or bones (198.5). If cancer originally develops elsewhere and metastasizes to the bladder, then assign code 198.1.

Symptoms
Bladder cancer does not typically produce signs and symptoms in the early stages. When symptoms do develop, they may include hematuria, pelvic pain, dysuria, frequent urination, feeling the need to urinate without being able to do so, and slow urinary stream.

Hematuria may be identified on a urine test or if the urine appears reddish or darker than normal. Other conditions that may cause hematuria include urinary tract infections, kidney disease, kidney or bladder stones, and prostate problems.

Diagnosis
The physician will perform a complete physical exam, including an internal exam. Other possible tests may include the following:

• urine cytology — checks for cancer cells but may miss low-grade cancers;

• cystoscopy — insertion of scope into the bladder to view the cancer and possibly take a biopsy sample;

• intravenous pyelogram — views the kidney and lower urinary tract;

• tumor marker test — checks the urine for proteins released by tumors; or

• fluorescence in situ hybridization — tests for chromosomal abnormalities often found in transitional cell carcinoma.

Staging
After bladder cancer is confirmed, additional tests, such as CT, MRI, bone scan, or chest x-ray, may be ordered to determine if the cancer has spread and/or metastasized. With the information obtained, the physician will stage the cancer as follows:

• Stage 0 — Cancer is confined to the surface of inner bladder lining. Also called carcinoma in situ, this cancer can be completely removed, but it does have a high rate of recurrence.

• Stage I — Cancer occurs in the bladder’s inner lining but hasn’t invaded the muscular bladder wall.

• Stage II — Cancer has invaded the bladder wall.

• Stage III — Cancer has spread through the bladder wall to the surrounding tissue. It may have also spread to the prostate in men or the uterus or vagina in women.

• Stage IV — Cancer has spread to the lymph nodes or other organs such as lungs, bones, or liver.

• Recurrent — Cancer has returned after having been treated. It may recur in the same place or in another part of the body.

Treatment
Surgery is the best treatment option. The most common procedure used to treat superficial bladder cancer is transurethral resection, which is classified to ICD-9-CM code 57.49. A cystoscope is inserted into the bladder through the urethra, and the cancer is removed with a small wire loop. The remaining cells are burned away by an electric current or a laser.

Segmental cystectomy (57.6) may be performed for cancer that goes deeper into the tissue, but is confined to one area of the bladder.

Radical cystectomy (57.71) removes the entire bladder and nearby lymph nodes. In men, the prostate gland, seminal vesicles, and a portion of the vas deferens are also removed. In females, the ovaries, fallopian tubes, and part of the vagina are also removed. According to coding directives, additional codes should be assigned for lymph node dissection (40.3, 40.5) and urinary diversion (56.51 to 56.79). A total cystectomy not documented as radical is classified to code 57.79.

Coding and sequencing for bladder cancer are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.