Part B Insider (Multispecialty) Coding Alert

Published on Wed Feb 15, 2012 PDF

Question: Our pathologist examined a biopsy from a screening colonoscopy that the physician performed because the 37-year-old patient's uncle had been diagnosed with colorectal cancer. The pathologist diagnosed an adenomatous polyp. Is the correct ICD-9 code V16.0, and is this a high-risk screening (V76.51)?

Answer: No, you should not report V16.0 (Family history of malignant neoplasm of gastrointestinal tract) as the diagnosis in this case. Instead, you should report the pathologist's findings, which is 211.3 (Benign neoplasm of colon).

To use V16.0, the patient should have a family history of first degree, which means that an immediate relative such as parents, siblings, or children (an uncle doesn't qualify). The pathologist wouldn't report this code in any event, because the pathologic findings provide the most specific diagnosis.

High risk screening: The following list shows the criteria under which a person can become eligible for a screening colonoscopy by reporting V76.51 (Special screening for malignant neoplasms colon) with the appropriate code:

• A family history (parent, sibling or children) of colorectal cancer or adenomatous polyp (V16.0, V18.51)
• A family history of hereditary non-polyposis colorectal cancer (V16.0)
• A family history of adenomatous polyposis (V18.51)
• A prior personal history of colorectal cancer (V10.00, V10.05)
• A prior personal history of adenomatous polyps (V12.72)
• A prior personal history of inflammatory bowel disease, including ulcerative colitis and Crohn's disease. Use the ICD-9 code for the specific form of IBD.

Report findings: Regardless of those requirements, the pathologist will only be billing for a service if the surgeon removes a specimen, so you should list the results of the biopsy as the diagnosis code on the pathology report.