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General Surgery Coding Alert

You Be the Coder:

153.3 Vs. V10.05 May Not be Clear

Published on Tue Jan 18, 2011

Question: Our surgeon placed a Medi-port for chemotherapy four months ago for a patient who had a colon resection for malignancy over six months ago. The patient has completed the course of treatment and is back in the office for the surgeon to inspect the incisions (resection and Medi-port) and to discuss when to schedule the Medi-port removal. The surgeon dictates the reason for the visit as "present colon cancer". Because the colon cancer treatment is complete, shouldn't the diagnosis be "history of colon cancer"?Answer: If all the treatment directed toward the primary cancer is complete, you are correct that the appropriate diagnosis would be history of colon cancer (V10.05, Personal history of malignant neoplasm of large intestine) Be careful not to use the personal history code, not the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).On the other hand, if the patient still has other [...]
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