General Surgery Coding Alert

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 treatment ongoing, such as radiation therapy, you should code the current colon cancer (153.3, Malignant neoplasm of sigmoid colon). Just because the surgeon is scheduling the port removal for the completed chemotherapy does not ensure that the patient does not have current cancer. For instance, radiation therapy does not require a port.

Bottom line: Don't change your surgeon's diagnosis based on your analysis of the situation. Consult with the physician if you have a question regarding the appropriateness of the diagnosis and determine the final code accordingly.