Malignant neoplasm of gallbladder
Chapter 2:Neoplasms
ICD-10 C23 is a billable code used to indicate a diagnosis of malignant neoplasm of gallbladder.
Malignant neoplasm of the gallbladder is a rare but aggressive form of cancer that arises from the epithelial cells lining the gallbladder. It is often associated with gallstones and chronic inflammation, which can lead to dysplasia and subsequent malignant transformation. Patients may present with nonspecific symptoms such as abdominal pain, jaundice, and weight loss, which can complicate early diagnosis. Imaging studies, including ultrasound, CT scans, and MRI, are crucial for identifying gallbladder masses, assessing the extent of disease, and evaluating for metastasis. Surgical resection remains the primary treatment modality, but due to the anatomical location and potential for local invasion, complete surgical excision can be challenging. The prognosis for gallbladder cancer is generally poor, with a five-year survival rate significantly lower than many other malignancies, primarily due to late-stage diagnosis. Multidisciplinary management involving surgical oncology, medical oncology, and radiology is essential for optimizing patient outcomes.
Detailed operative reports, including type of resection and findings.
Patients undergoing cholecystectomy for suspected malignancy.
Ensure documentation reflects the complexity of the surgical procedure and any complications.
Comprehensive imaging reports detailing findings and recommendations.
Imaging for staging and follow-up of gallbladder cancer.
Clear documentation of imaging techniques and findings is crucial for accurate coding.
Used when a patient with suspected gallbladder cancer undergoes surgery.
Operative report detailing the procedure and findings.
Surgical oncology must document any findings that indicate malignancy.
Common symptoms include abdominal pain, jaundice, unexplained weight loss, and nausea. However, symptoms can be vague and may not appear until the cancer is advanced.
