Colorectal Cancer Documentation Guide
Malignant neoplasm of the colon or rectum, one of the most common cancers worldwide.
ICD-10 Codes: C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20
Common Symptoms
- Change in bowel habits
- Rectal bleeding
- Abdominal pain
- Unexplained weight loss
- Iron deficiency anemia
Key Documentation Elements
- Anatomic site (cecum, ascending, transverse, sigmoid, rectum)
- TNM staging and AJCC stage grouping
- Molecular markers (MSI/dMMR, KRAS, NRAS, BRAF, HER2)
- Treatment plan (surgery, chemotherapy, radiation, immunotherapy)
- Surveillance schedule (colonoscopy, CEA, imaging intervals)
Documentation Challenges
- Documenting precise anatomic site and TNM staging
- Recording molecular marker results (MSI, KRAS, BRAF, HER2)
- Capturing treatment response assessment (RECIST criteria)
- Tracking surveillance colonoscopy and CEA monitoring schedule
Billing Considerations
- Site-specific coding (C18.0 cecum through C20 rectum)
- Active treatment vs surveillance phase coding
- Chemotherapy administration and molecular testing billing
Frequently Asked Questions
How is colorectal cancer coded by site?
CRC codes are site-specific: C18.0 (cecum), C18.2 (ascending), C18.4 (transverse), C18.7 (sigmoid), C19 (rectosigmoid), C20 (rectum). Scribeable maps your documented tumor location to the correct anatomic code.
How does Scribeable support oncology documentation?
Scribeable captures staging data, molecular markers, treatment regimens, response assessments, and surveillance plans from your encounter, creating structured cancer management documentation.