Gastroenterology Coding Alert

Question: When should I use a diagnosis of colorectal cancer versus a diagnosis of history of colon cancer? How much time has to elapse or what must the patient's physical condition be?

Pennsylvania Subscriber

Answer: An ICD-9 code for malignant neoplasm of the large intestine (153.0-153.9 for various sites in the colon, and 154.0-154.8 for various sites in the rectum, rectosigmoid junction, and anus) is used to report colorectal cancer when it is present. This is generally used as a diagnosis only for the colonoscopy during which the original lesion is discovered. The same diagnosis code can also be used for immediate follow-up visits to discuss treatment options and perform additional workup. If the lesion is unresectable, you can continue to use that diagnosis for follow-up visits.
 
Once the cancer discovered during that procedure is removed and the patient returns for follow-up visits or for a surveillance colonoscopy, V10.05 (personal history of malignant neoplasm, large intestine) or V10.06 (personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus) should be reported.
 
Although Medicare and private insurers are known to deny most procedures that have a v code as the diagnosis, this situation is one of the exceptions, and you should not hesitate to use the personal-history diagnosis if that is appropriate. Most Medicare carriers and payers list V10.05 and V10.06 as covered diagnoses for diagnostic or therapeutic colonoscopy. Most medical polices will allow surveillance colonoscopies in one year and then every three to five years following resection of the colorectal cancer or neoplastic polyp, and in less than one year if the polyp is large, sessile or has carcinoma in situ.
 
Some carriers have slightly different policies that may require you to bill for a screening colonoscopy (G0105) with the personal-history diagnosis, however. California's Part B Carrier, National Heritage Insurance Company, for example, states in its local medical review policy that surveillance colonoscopies performed more than 23 months after resection should be billed as a high-risk screening.