Question: A patient developed hypoinsulinemia and diabetes after our surgeon performed a Whipple procedure involving a total pancreatectomy to treat pancreatic cancer in the head of the pancreas. Our surgeon is providing surgical aftercare, while, simultaneously, an oncologist is planning chemotherapy and radiation. What diagnosis codes should we use for this case? Washington Subscriber Answer: For encounters with your surgeon following the Whipple procedure, you’ll need to code However, the primary diagnosis would be the indication that the encounter is for post-procedural care by listing Z48.3 (Aftercare following surgery for neoplasm). For more detail and the guidance to support the order and codes, see the official coding guidelines for Section 1.C.21.c.7.
Note: If the treatment is in any way directed at the complications following surgery, you should “designate the complication as the principal or first-listed diagnosis if the treatment is directed at resolving that complication,” according to the ICD-10-CM Official Guidelines for Coding and Reporting (FY 2021, Page 35 of 126). These codes include:the cancer as C25.0 (Malignant neoplasm of head of pancreas). Although the cancer was surgically removed, the patient is in ongoing treatment using chemotherapy and radiation therapy, so you should not use the personal history code.