General Surgery Coding Alert

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 neoplasm of large intestine). You should not use the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).

Don't report the cancer diagnosis, 153.3 (Malignant neoplasm of sigmoid colon) for this patient encounter.