October 1, 2007

Coding for Pancreatic Cancer
For The Record
Vol. 19 No. 20 P. 53

Pancreatic cancer occurs when malignant cells form in pancreatic tissues. The pancreas’ function is to secrete enzymes and hormones that aid in digestion and metabolism.

The ICD-9-CM code assignment depends on the malignant neoplasm’s location in the pancreas, such as the following:

• head of pancreas (157.0);

• body of pancreas (157.1);

• tail of pancreas (157.2); or

• pancreatic duct (157.3).

If the malignant neoplasm is of contiguous or overlapping sites of the pancreas and the point of origin cannot be determined, assign code 157.8. Carcinoma in situ of the pancreas is classified to code 230.9. Pancreatic cancer is usually not diagnosed in the early stages and rapidly spreads. Surgery is the only option for a cure, but it is not an option when the cancer has spread to other parts of the body.

Types
Most pancreatic tumors originate in the acinar cells and are considered an adenocarcinoma. However, a small percentage begin in the islet cells and are called endocrine tumors. Examples of endocrine tumors include glucagonomas and insulinomas, which are classified to code 157.4 if documented as malignant or code 211.7 if benign or unspecified. Assign an additional code to identify any functional activity.

Tumors can also develop in the ampulla of Vater called ampullary cancers. The ampulla of Vater is where the bile and pancreatic ducts empty into the small intestine. A malignant neoplasm of the ampulla of Vater is classified to code 156.2. If the tumor was documented as benign, assign code 211.5.

Signs and Symptoms
Typically, signs and symptoms of pancreatic cancer do not appear until the disease is advanced or has spread to other parts of the body. When symptoms do appear, they may include upper abdominal pain radiating to the middle or the upper back; loss of appetite; significant weight loss; jaundice; itching due to high levels of bile acids accumulating in the skin; nausea and vomiting; problems with digesting foods; and problems with blood sugar metabolism.

Diagnosis
If the physician suspects pancreatic cancer, the following tests may be performed to confirm the diagnosis:

• ultrasound imaging (88.74);

• CT scan (88.01);

• MRI (88.87);
• endoscopic retrograde cholangiopancreatiogaphy (51.10);

• endoscopic ultrasound (88.74 and a code for the endoscopy—code assignment will depend on location)

• percutaneous transhepatic cholangiography (87.51);

• biopsy of pancreas (open—52.12; closed, needle, percutaneous—52.11); or

• laparoscopy (54.21).

Staging
Staging determines the size and location of cancer and whether it has spread. One staging method includes the following:

• Respectable — all tumor nodules can be removed.

• Locally advanced — cancer has spread to tissues around the pancreas or into the blood vessels and can no longer be completely removed.

• Metastatic — cancer has spread to distant organs such as the lungs or liver.

The physician may also use the following staging method:

• Stage 1 — cancer is confined to the pancreas.

• Stage 2 — cancer has spread somewhat, such as to the surrounding lymph nodes, but not into large blood vessels nearby

• Stage 3 — cancer has invaded large blood vessels but hasn’t spread to distant organs.

• Stage 4 — cancer has spread to distant organs.

Treatment
Treatment depends on the cancer’s stage and location, as well as the patient’s overall health, age, and personal preferences. Some surgical procedures used to resect the tumor completely include the following:

• Whipple procedure (pacreaticoduodenectomy) involves removing the head of the pancreas, duodenum, gallbladder, and a portion of the common bile duct. Sometimes, a portion of the stomach is also removed. The Whipple procedure is classified to code 52.7 (AHA Coding Clinic for ICD-9-CM, 2001, first quarter, page 13).

• Total pancreatectomy (52.6) removes the entire pancreas. Code 52.6 also includes synchronous duodenectomy.

• Distal pancreatectomy (52.52) removes the tail and possibly a portion of the body of the pancreas.

Radiation therapy may be used in conjunction with surgery. In addition, intraoperative electron beam radiation is now being used, allowing the surgeon to direct high-energy particles at the pancreas during surgery, sparing nearby organs. However, the patient may receive radiation treatments in combination with chemotherapy if the cancer can’t be treated surgically.

Chemotherapy is typically used when the pancreatic cancer has metastasized but does not improve the patient’s survival percentage. The standard chemotherapy drug for pancreatic cancer is gemcitabine.

Coding and sequencing for pancreatic 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.