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Malignant Neoplasm of the Anus and Anal Canal B027

Document
Last amended 
30 June 2015
Current RMA Instruments:
Reasonable Hypothesis SOP
51 of 2013
Balance of Probabilities SOP
52 of 2013
Changes from Previous Instruments:

SOP Bulletin 167

ICD Coding:
  • ICD-9-CM Codes: 154.2, 154.3, 154.8, 230.5, 230.6
  • ICD-10-AM Codes: C21.0, C21.1, C21.2, D01.3
Is specific diagnostic evidence required to apply the SOP?Yes.

This is a histological diagnosis based on biopsy or operative specimen. The relevant medical specialist is a general surgeon, oncologist or gastroenterologist.

Are there sub-factors that require specific information? – No.
Additional diagnoses covered by SOP
  • Adenocarcinoma of the anus / anal canal
  • Squamous cell carcinoma of the anus / anal canal
  • Carcinoma in situ of the anus / anal canal
Conditions not covered by SOP
  • Hodgkin’s lymphoma of the anus / anal canal, use ICD code 201.9
  • Malignant melanoma of the anus / anal canal
  • Malignant neoplasm of anal margin, ICD-9 code 173.5
  • Malignant neoplasm of perianal skin, ICD-9 code 173.5
  • Malignant neoplasm of the rectum, ICD-9 code 154.1
  • Non-Hodgkin’s lymphoma of the anus / anal canal, use ICD code 202.8
  • Soft tissue sarcoma of the anus / anal canal, use ICD code 171.8
Unconfirmed diagnosis

If, after considering the above information you are unable to apply the SOP, you should then:

  1. seek medical officer advice about further investigation, or;
  2. re-encode the condition, if appropriate.

The following investigations may be useful in establishing the diagnosis.

  • report from a gastroenterologist
  • upper GI endoscopy report