ICD-10 Coding for Cecal Mass(C18.0, D12.2, K63.5)
Complete ICD-10-CM coding and documentation guide for Cecal Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cecal Mass
C18-C20Primary Range
Malignant neoplasms of the colon, rectosigmoid junction, rectum, anus, and anal canal
This range includes codes for malignant neoplasms of the cecum, which is the primary focus for cecal mass coding.
Benign neoplasms of the digestive system
This range includes codes for benign neoplasms of the cecum, relevant for non-malignant cecal masses.
Other diseases of the intestine
This range includes codes for non-neoplastic conditions such as polyps that may be found in the cecum.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C18.0 | Malignant neoplasm of cecum | Use when a malignant neoplasm of the cecum is confirmed by histology. |
|
| D12.2 | Benign neoplasm of cecum | Use when a benign neoplasm is confirmed by histology. |
|
| K63.5 | Polyp of colon | Use for non-neoplastic polyps confirmed by histology. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for cecal mass
Essential facts and insights about Cecal Mass
Primary ICD-10-CM Codes for cecal mass
Decision Criteria
clinical Criteria
- Histology confirms adenocarcinoma
documentation Criteria
- Colonoscopy findings with biopsy results
Applicable To
- Adenocarcinoma of cecum
- Signet ring cell carcinoma of cecum
Clinical Validation Requirements
- Histology report confirming adenocarcinoma
- CT/MRI showing cecal lesion
- Colonoscopy findings with biopsy results
Code-Specific Risks
- Incorrectly coding as unspecified (C18.9) when the site is known.
Coding Notes
- Ensure histological confirmation before coding as malignant.
D12.2 - Benign neoplasm of cecum
Use when a benign neoplasm is confirmed by histology.
Applicable To
- Tubular adenoma of cecum
Excludes
- Malignant neoplasm of cecum (C18.0)
Clinical Validation Requirements
- Endoscopic images showing polyp location
- Pathology report confirming no high-grade dysplasia
Coding Notes
Ensure histological confirmation of benign status.
K63.5 - Polyp of colon
Use for non-neoplastic polyps confirmed by histology.
Applicable To
- Hyperplastic polyp of cecum
Excludes
- Neoplastic polyps (D12.2, C18.0)
Clinical Validation Requirements
- Colonoscopy findings with polyp description
- Histology confirming non-neoplastic nature
Coding Notes
Ensure histological confirmation of non-neoplastic status.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cecal Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C18.0.
Impact
Clinical: Leads to misdiagnosis or delayed treatment, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials or reduced reimbursement
Mitigation Strategy
Ensure detailed documentation of mass size, location, and histology, Use structured templates for procedure notes
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data affecting patient records
Mitigation Strategy
Always specify cecum (C18.0) if visualized/proven
Impact
Reimbursement: Potential denial of claims due to incorrect coding, Compliance: Violation of coding standards, Data Quality: Misrepresentation of clinical condition
Mitigation Strategy
Use D12.2 for adenomas ≥10mm or with dysplasia
Impact
Failure to document histology can lead to incorrect coding.
Mitigation Strategy
Ensure biopsy results are included in the patient's record.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Cecal Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cecal Mass
Use these documentation templates to ensure complete and accurate documentation for Cecal Mass. These templates include all required elements for proper coding and billing.
Colonoscopy with biopsy
Specialty: GastroenterologyRequired Elements
- Colonoscopy findings
- Biopsy results
- Histology confirmation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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