Advanced Search

General Surgery Coding Alert

Reader questions:

153.3 Vs. V10.05 -- Get the History Right

Published on Wed Nov 17, 2010

Question: We have a patient who had a colon resection for cancer over six months ago. Two months following surgery, he had a Mediport inserted for chemotherapy. The patient has completed the course of treatment and comes to our surgeon's office to discuss when to schedule the Medi-port removal because he is in remission. Our surgeon also inspects the incisions from the initial resection and the Medi-port insertion. The surgeon dictates the diagnosis for the service as "colon cancer" even though he's scheduling the Medi-port removal because the colon cancer treatment is complete. Shouldn't the diagnosis be "history of colon cancer"? Answer: You are correct that if all treatment directed toward the cancer is complete and there are no indications of current disease, you should use a history of cancer code instead of a cancer code. Do this: Report the reason for the encounter as V10.05 (Personal history of malignant [...]
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

General Surgery Coding Alert

View All