Ob-Gyn Coding Alert

Question: We see a patient every six months for a history of uterine cancer. We do not perform a Pap smear or pelvic examination, only an E/M service. The patient is not taking any medications for the disease. What should we use as the diagnosis code?

Indiana Subscriber

Answer: According to ICD-9 rules, you should use the "history of" code (V10.42, Personal history of malignant neoplasm; other parts of uterus) as your primary diagnosis if that is the only reason you are seeing the patient.

The American Hospital Association (AHA) Coding Clinic guidelines state, "When the primary malignancy has been previously excised or eradicated from its site and there is no adjunct treatment directed to that site and no evidence of any remaining malignancy at the primary site, use the appropriate code from the V10 series to indicate the former site of primary malignancy. Any mention of extension, invasion, or metastasis to a nearby structure or organ or to a distant site is coded as a secondary malignant neoplasm to that site and may be the principal diagnosis in the absence of the primary site."

Although this is proper coding, some payers may not accept the V10 codes as a primary diagnosis. You should appeal, detailing the reason for the visits and supplying the guidance from AHA.