Summary & Overview
CPT 3386F: Stage II Colon Cancer Diagnosis and Documentation
CPT code 3386F documents a clinician’s diagnosis of stage II colon cancer in adults, indicating tumor invasion beyond the muscularis propria into pericolorectal tissues and potential involvement of the visceral peritoneum or adjacent organs. Nationally, accurate staging documentation using this code is essential for treatment planning, quality measurement, and claims processing across oncology and surgical services. Key payers relevant to national reimbursement and coverage practices include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. This publication provides a concise overview of CPT code 3386F, explaining its clinical meaning, typical care settings, and the implications for billing and quality reporting. Readers will find a clear clinical context for the code, the list of major payers addressed in typical national analyses, and a breakdown of what information is available versus missing in the source documentation. Benchmarks, policy updates, and coding relationships are noted where available; where input data is incomplete, the publication flags missing elements such as specific ICD-10 mappings, modifiers, and related codes. The goal is to equip coders, billing professionals, and policy analysts with a focused reference on CPT code 3386F to support accurate documentation and alignment with payer expectations.
Billing Code Overview
CPT code 3386F indicates that a provider has diagnosed an adult patient (age 18 or older) with stage II colon cancer, documenting tumor invasion from the muscularis propria into the pericolorectal tissues, possibly reaching the visceral peritoneum and adhering to or invading adjacent organs or structures.
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Service type: Diagnostic cancer staging and documentation of colon malignancy severity
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Typical site of service: Oncology clinic, hospital inpatient or outpatient surgical service, or specialty cancer center
Data not available in the input for modifiers, taxonomies, ICD-10 diagnoses, related codes, and service line.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult aged 18 years or older who presents with symptoms such as a change in bowel habits, rectal bleeding, unexplained weight loss, or abdominal pain. Diagnostic workup includes colonoscopy with biopsy confirming adenocarcinoma of the colon. Imaging (CT chest/abdomen/pelvis) and pathology staging classify the tumor as stage II (tumor invades through the muscularis propria into pericolorectal tissues; may involve visceral peritoneum or directly invade nearby organs). The clinical workflow includes multidisciplinary review (medical oncology, surgical oncology, radiation oncology as appropriate), preoperative counseling, perioperative optimization, colectomy or segmental resection by a colorectal surgeon, and documentation of pathologic stage. Postoperative care includes adjuvant therapy discussion if high-risk features are present, surveillance planning, and coordination of billing where the diagnosis and stage stage II are clearly documented in the medical record for coder assignment and quality measures reporting.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when a distinct E/M is performed and documented on the same day as the surgical procedure for decision-making, consent, or pre-op evaluation |