Whip Your Pancreatic Cancer Coding Into Shape
Sport purple and shore up your coding practices in support of Pancreatic Cancer Awareness Month.
November is Pancreatic Cancer Awareness Month and Nov. 19 is World Pancreatic Cancer Day — a time when people across the globe unite in the fight against the world’s toughest cancer. These events provide unique opportunities to raise awareness about the symptoms and risks of the disease and the urgent need for earlier detection. Show your support this month by wearing purple and reviewing the codes for pancreatic cancer and the diagnostic and therapeutic measures used in the battle against this deadly disease.
Detecting Pancreatic Cancer
For individuals who aren’t at an increased risk of developing pancreatic cancer, there is no recommended screening routine. As such, a workup is typically only done if a person has signs or symptoms that may be caused by pancreatic cancer. A definitive diagnosis requires a series of imaging scans, blood tests, and biopsies — as there is no single diagnostic test that can determine if someone has pancreatic cancer.
Imaging tests create pictures of a person’s internal organs to help doctors visualize structures such as the pancreas. Familiarize yourself with the following techniques used to diagnose pancreatic cancer and examples of codes used to report these services:
- Ultrasonography: uses sound waves to create an image. Codes include:
- 76700 Ultrasound, abdominal, real time with image documentation; complete
- 76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
- Computerized tomography (CT) scan: uses X-rays to create pictures of cross-sections of the body. Coding is dependent on several factors, including the location of the scan and whether contrast material is used. CPT® codes used to report the various types of CT scans that may be performed as part of a workup for pancreatic cancer include:
- 74150 Computed tomography, abdomen; without contrast material
- 74160 Computed tomography, abdomen; with contrast material(s)
- 74176 Computed tomography, abdomen and pelvis; without contrast material
- 74177 Computed tomography, abdomen and pelvis; with contrast material(s)
- Magnetic resonance imaging (MRI): uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in the body. Codes include:
- 74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)
- 74182 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)
- 74183 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
- Positron emission tomography (PET) scan: uses special dye containing radioactive tracers to create color images that show how the body’s cells are working. If a PET scan of the patient’s entire body is performed, report the procedure using code 78813 Positron emission tomography (PET) imaging; whole body.
- Endoscopic ultrasound (EUS): uses an ultrasound device passed through a thin, flexible tube (endoscope) to make images of the pancreas from inside the abdomen. Code selection is based on what part of the gastrointestinal tract is being scoped. For example, if the esophagus is examined via EUS, report 43231 Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination.
- Biopsy is a procedure to remove a small sample of tissue for microscopic examination. A person’s medical history, physical exam, and imaging test results may strongly suggest pancreatic cancer, but usually the only way to be sure is to remove a small sample of the tumor and look at it under a microscope. Codes include 48100 Biopsy of pancreas, open (eg, fine needle aspiration, needle core biopsy, wedge biopsy) and 48102 Biopsy of pancreas, percutaneous needle.
- Blood tests can detect specific proteins (tumor markers) shed by pancreatic cancer cells. One tumor marker test used in pancreatic cancer is called CA19-9. Unfortunately, it isn’t helpful in screening patients because levels of this protein do not reliably reflect the presence of pancreatic cancer. But CA19-9 may be helpful in monitoring how the cancer responds to therapy.
Report testing for CA19-9 using CPT® code 86301 Immunoassay for tumor antigen, quantitative; CA 19-9. Note: Some payers, including the Centers for Medicare & Medicaid Services (CMS), do not cover this test for the evaluation of patients with signs or symptoms suggestive of malignancy. It can be ordered when it is necessary to assess either the presence of recurrent disease or the patient’s response to treatment with subsequent treatment cycles.
Tumor Location Drives Diagnosis Coding
Once testing has confirmed a diagnosis of pancreatic cancer, the next step is determining the right code to describe the patient’s condition. To assign the correct ICD-10-CM code, you must know where the malignant neoplasm is located in the pancreas:
C25 Malignant neoplasm of pancreas
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas/ D13.7 Benign neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
Coding Surgeries for Pancreatic Cancer
Once you’ve determined the appropriate diagnosis code, the next hurdle is to figure out how to document any therapeutic measures performed, which may include surgery, chemotherapy, radiation therapy, or a combination of these depending on the extent of the disease. For most people, the first goal of pancreatic cancer treatment is to eliminate the cancer, when possible. The coding for operations used for tumor excision in people with pancreatic cancer include:
- Distal pancreatectomy: surgery for tumors in the pancreatic body and tail. Involves removal of the left side (tail and possibly a portion of the body) of the pancreas. The spleen may also need to be removed. Code 48145 includes anastomosis of the pancreatic duct with the jejunum (pancreatojejunostomy) — 48146 does not include this repair.
- 48145 Pancreatectomy, distal subtotal, with or without splenectomy; with
- 48146 Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure)
- 48145 Pancreatectomy, distal subtotal, with or without splenectomy; with
- Total pancreatectomy: surgery to remove the entire pancreas, as well as the gallbladder, spleen, and part of the stomach and small intestine. Report this procedure with code 48155 Pancreatectomy, total.
- Whipple procedure (pancreaticoduodenectomy, pancreatoduodenectomy): surgery to remove tumors in the head of the pancreas. The surgical goal is primarily to excise the head of the pancreas, but often, due to the nature of the organ and disease, additional resections are needed. The surgeon then reconnects the remaining parts of the pancreas, stomach, and intestines to allow for food digestion.
All Whipple procedures involve:
- Removal of the head of the pancreas (partial pancreatectomy; subtotal)
- Removal of at least a portion of the duodenum (duodenectomy)
- Joining of the common bile duct to the intestine (choledochoenterostomy)
Additional steps: In some situations, in addition to the mandatory steps above, a Whipple procedure may include the removal of the gallbladder (cholecystectomy), surrounding lymph nodes (lymphadenectomy), and/or a portion of the stomach (partial gastrectomy), as well as the creation of a connection between the stomach and jejunum (gastrojejunostomy), the duodenum and jejunum (duodenojejunostomy), and/or the jejunum and pancreatic duct (pancreatojejunostomy).
Use the following codes to report a Whipple procedure:
48150 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy
48152 without pancreatojejunostomy
48153 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy
48154 without pancreatojejunostomy
Because the two Whipple code families are differentiated by whether a total or partial duodenectomy is performed, you should scan the op note to see if the surgeon removed all or a portion of the duodenum, the first (proximal) section of the small intestine.
Codes 48150 and 48152 describe the standard Whipple procedure, with removal of the entire duodenum, removal of part of the stomach, and anastomosis of the stomach to the jejunum. Code 48150 includes anastomosis of the pancreatic duct with the jejunum — 48152 does not include this repair.
Codes 48153 and 48154 describe the same procedures, by the pylorus-sparing technique. The pylorus-sparing pancreaticoduodenectomy involves partial removal of the duodenum and anastomosis of the duodenum to the jejunum rather than the stomach.
If the op note describes a partial gastrectomy and gastrojejunostomy, the procedure must have included a total duodenectomy. If the op note describes a duodenojejunostomy, that’s evidence of a partial duodenectomy.
Now that you’ve brushed up on your pancreatic cancer coding, be sure to read the accompanying article in this issue, “Heighten Awareness of Pancreatic Cancer,” to learn how you can fight back against and raise awareness of pancreatic cancer.
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