Gastroenterology Coding Alert

Question: A colonoscopy was performed "to examine the remainder of the colon" on a patient who was recently diagnosed with rectal cancer by another physician. He is not a Medicare patient. Should I use a diagnosis of V76.51 (Special screening for malignant neoplasms of the colon) followed by 154.1 (Malignant neoplasm of rectum)? Or should I just code for the rectal cancer?

Washington Subscriber

Answer: If the other physician established that the patient has rectal cancer and no surgery has been performed to remove the cancer, you should use the diagnosis of rectal cancer (154.1). This is common in gastroenterology. Often a primary care physician will perform a flexible sigmoidoscopy and discover that the patient has rectal cancer. Before surgery is performed, the surgeon will refer the patient to a gastroenterologist for a colonoscopy to make sure the cancer hasn't spread to other parts of the colon.

A diagnosis of cancer is generally used when the original lesion is discovered and for immediate follow-up visits or procedures. If the patient has had surgery to remove the cancer and is seeing your gastroenterologist for a surveillance colonoscopy, you should report V10.06 (Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus).