ICD-10 Coding for History of Rectal Cancer(Z85.048, Z85.038)
Complete ICD-10-CM coding and documentation guide for History of Rectal Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Rectal Cancer
Z85.048Primary Range
Personal history of malignant neoplasm of rectum
Used when documenting a patient's history of rectal cancer after treatment completion and no evidence of disease.
Personal history of other malignant neoplasms of large intestine
Applicable if the cancer was located at the rectosigmoid junction.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z85.048 | Personal history of malignant neoplasm of rectum | Use when the patient has completed treatment and there is no evidence of active disease. |
|
| Z85.038 | Personal history of other malignant neoplasms of large intestine | Use when the cancer was located at the rectosigmoid junction and is no longer active. |
|
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 history of rectal cancer
Essential facts and insights about History of Rectal Cancer
Primary ICD-10-CM Codes for history of rectal cancer
Decision Criteria
clinical Criteria
- Patient has completed treatment and is cancer-free.
coding Criteria
- No active treatment or recurrence is documented.
Applicable To
- History of rectal cancer
Excludes
- Current rectal cancer (C20)
Clinical Validation Requirements
- Documented 'no evidence of disease'
- Surveillance imaging shows no recurrence
- Patient completed curative-intent treatment
Code-Specific Risks
- Misclassification if active treatment is ongoing
Coding Notes
- Ensure documentation clearly states 'no evidence of disease' to support the use of Z85.048.
Z85.038 - Personal history of other malignant neoplasms of large intestine
Use when the cancer was located at the rectosigmoid junction and is no longer active.
Applicable To
- History of rectosigmoid junction cancer
Excludes
- Current rectosigmoid cancer (C19)
Clinical Validation Requirements
- Documented history of rectosigmoid junction cancer
- No active disease
Coding Notes
Ensure the specific site of the previous cancer is documented to differentiate from rectal cancer.
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 History of Rectal Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.048.
Impact
Clinical: Misrepresents patient's current health status., Regulatory: Non-compliance with ICD-10 guidelines., Financial: Potential for claim denial or audit.
Mitigation Strategy
Review current treatment status, Ensure documentation reflects 'no evidence of disease'
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of patient records.
Mitigation Strategy
Ensure documentation specifies 'rectal' to avoid misclassification.
Impact
Using history codes when cancer is still active.
Mitigation Strategy
Regularly update patient records and verify treatment status.
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 History of Rectal Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Rectal Cancer
Use these documentation templates to ensure complete and accurate documentation for History of Rectal Cancer. These templates include all required elements for proper coding and billing.
Surveillance colonoscopy
Specialty: GastroenterologyRequired Elements
- Patient history of rectal cancer
- Current surveillance status
- Findings from colonoscopy
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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