Gastroenterology Coding Alert

Question: A non-Medicare patient who was recently diagnosed with rectal cancer underwent a colonoscopy "to examine the remainder of the colon." She was diagnosed by another physician. What code should I report, for screening or rectal cancer?

Virginia Subscriber

Answer: Since another physician diagnosed the patient's rectal cancer, and assuming the patient has not undergone any surgery to remove the cancer, you should go for the diagnosis of rectal cancer (154.1, Malignant neoplasm of rectum, rectosigmoid junction, and anus; rectum). Your case is fairly common in gastroenterology where a primarycare 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.

Who discovers the original lesion should report the rectal cancer ICD-9. 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).