General Surgery Coding Alert

Question: The surgeon performed colonoscopy "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? Or should I just code for the rectal cancer?

Washington Subscriber

Answer: If the other physician established that the patient has rectal cancer and the patient has not completed treatment to remove the cancer, you should use the rectal cancer diagnosis (154.1, Malignant neoplasm of rectum, rectosigmoid junction, and anus; rectum).

Often a primary-care physician will perform a flexible sigmoidoscopy and discover that the patient has rectal cancer. Prior to surgery, the surgeon may perform a colonoscopy to make sure there is no synchronous colon cancers undiagnosed.

You-ll generally use a cancer diagnosis when a physician discovers the original lesion and for related follow-up visits or procedures. If the patient has had surgery to remove the cancer and has completed the course of treatment for that cancer, you would report V10.06 (Personal history of malignant neoplasm; rectum, rectosigmoid junction, and anus) for subsequent screenings.

Tip: For more information on "history of cancer" diagnoses, see the next question, "History Begins When Active Treatment Ends."