2025 ICD-10-CM code C78.5
(Active) Effective Date: N/A Neoplasms - Secondary malignant neoplasm of large intestine and rectum Chapter 2: Neoplasms (C00-D49) Feed
Secondary malignant neoplasm of the large intestine and rectum.
Medical necessity for diagnostic tests and treatment is established by the presence of signs, symptoms, or history suggestive of metastatic disease in the large intestine and rectum. The medical record should clearly document the clinical rationale for procedures and interventions.
Clinicians should document the patient's symptoms, such as abdominal pain, changes in bowel habits, fatigue, weight loss, and diarrhea. Physical examination findings, including abdominal swelling, enlargement, and tenderness upon palpation, are also essential. Laboratory tests, such as CBC, LFTs, kidney function tests, and tumor marker tests, aid in diagnosis. Diagnostic imaging, including abdominal X-rays, CT scans, MRI, colonoscopy with biopsy, PET scans, and barium enemas, plays a crucial role. Treatment aims to control symptoms, prevent metastasis, and improve quality of life. Options include surgical resection, chemotherapy, and radiation therapy.
- Chapter 2: Neoplasms (C00-D49)
- Malignant neoplasms (C00-C97)Malignant neoplasms, stated or presumed to be primary (of specified sites), and certain specified histologies, except neuroendocrine, and of lymphoid, hematopoietic and related tissue (C00-C75)Malignant neoplasms of ill-defined, other secondary and unspecified sites (C76-C80)
In simple words: This code indicates that cancer has spread from another part of the body to the large intestine and rectum.
Secondary malignant neoplasm of the large intestine and rectum refers to the spread of cancer cells from a primary cancer site to the large intestine and rectum through the bloodstream or lymphatic channels.
Example 1: A patient with a history of breast cancer presents with abdominal pain and altered bowel habits. Colonoscopy reveals a mass in the rectum, and biopsy confirms metastatic adenocarcinoma consistent with the primary breast cancer. The diagnosis is secondary malignant neoplasm of the large intestine and rectum (C78.5)., A patient with a history of lung cancer experiences weight loss, fatigue, and rectal bleeding. Imaging studies reveal multiple lesions in the large intestine. Biopsy confirms metastatic lung cancer. The appropriate diagnosis code is C78.5., A patient undergoing treatment for melanoma develops changes in bowel habits. Further investigation with colonoscopy and biopsy confirms the presence of melanoma cells in the colon. C78.5 is used to code the secondary malignancy in the large intestine.
Documentation should include the primary cancer site, location of the secondary malignancy in the large intestine and rectum, confirmation of metastasis through biopsy or imaging, and associated symptoms.
- Specialties:Oncology, gastroenterology, general surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office