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ICD-10 Guide
ICD-10 CodesC16.2

C16.2

Billable

Malignant neoplasm of body of stomach

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 C16.2 is a billable code used to indicate a diagnosis of malignant neoplasm of body of stomach.

Key Diagnostic Point:

C16.2 refers to a malignant neoplasm located specifically in the body of the stomach, which is the central portion of the stomach between the fundus and the pylorus. Gastric cancer, or stomach cancer, is often associated with chronic infection by Helicobacter pylori (H. pylori), a bacterium that can lead to chronic gastritis and is a significant risk factor for the development of gastric adenocarcinoma. The disease typically presents with nonspecific symptoms such as abdominal pain, weight loss, and early satiety, which can complicate early diagnosis. Staging of gastric cancer is crucial for determining treatment options and prognosis, with the TNM classification system being the most widely used. Treatment often involves surgical intervention, such as gastrectomy, which may be total or partial depending on the extent of the disease. Postoperative care and monitoring for recurrence are essential components of management. Accurate coding for C16.2 requires comprehensive documentation of the diagnosis, staging, and treatment plan.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for precise documentation of tumor location and staging
  • Differentiation between types of gastric cancer (e.g., adenocarcinoma vs. lymphoma)
  • Association with H. pylori and its implications for treatment
  • Variability in surgical procedures (e.g., total vs. partial gastrectomy)

Audit Risk Factors

  • Inadequate documentation of staging
  • Failure to document H. pylori status
  • Incorrect coding of surgical procedures
  • Lack of follow-up documentation post-gastrectomy

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans.

Common Clinical Scenarios

Diagnosis and management of gastric cancer, staging evaluations, and treatment planning.

Billing Considerations

Ensure accurate documentation of tumor characteristics and treatment response.

Gastroenterology

Documentation Requirements

Endoscopy reports, biopsy results, and H. pylori testing.

Common Clinical Scenarios

Evaluation of gastric symptoms, management of H. pylori infection, and surveillance for gastric cancer.

Billing Considerations

Documenting the relationship between H. pylori and gastric cancer risk.

Coding Guidelines

Inclusion Criteria

Use C16.2 When
  • According to ICD
  • CM guidelines, C16
  • 2 should be used when the documentation specifies a malignant neoplasm of the body of the stomach
  • Coders must ensure that the diagnosis is confirmed by pathology and that staging is documented

Exclusion Criteria

Do NOT use C16.2 When
  • Exclusion criteria include benign neoplasms and other specified gastric conditions

Related ICD-10 Codes

Related CPT Codes

43631CPT Code

Laparoscopic total gastrectomy

Clinical Scenario

Used for patients with localized gastric cancer requiring surgical intervention.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Oncologists and surgeons must coordinate documentation for accurate coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of gastric cancer, improving data accuracy and facilitating better tracking of treatment outcomes and epidemiological studies.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of gastric cancer, improving data accuracy and facilitating better tracking of treatment outcomes and epidemiological studies.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of gastric cancer, improving data accuracy and facilitating better tracking of treatment outcomes and epidemiological studies.

Resources

Clinical References

  • •
    American Cancer Society - Stomach Cancer

Coding & Billing References

  • •
    American Cancer Society - Stomach Cancer

Frequently Asked Questions

What is the significance of H. pylori in gastric cancer?

H. pylori infection is a major risk factor for gastric cancer, as it can lead to chronic inflammation and changes in gastric mucosa that predispose to malignancy.