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In a particular scenario, our surgeon placed a Medi-port for chemotherapy four months back for a patient who had a colon resection for malignancy over six months back. The patient has finished the course of treatment and is back in the office for the surgeon to inspect the incisions (resection and Medi-port) and to talk about when to schedule the Medi-port removal. The surgeon dictates the cause for the visit as 'present colon cancer'. Since the colon cancer treatment is complete, should not the diagnosis be 'history of colon cancer'? Well, if all the treatment pointed toward the primary cancer is complete, you are right that the proper diagnosis would be history of colon cancer (V10.05, Personal history of malignant neoplasm of large intestine). Be cautious not to use the personal history code, and not the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract). In contrast, if the patient still has other treatment ongoing, say for instance radiation therapy, you should report the proper colon cancer 153.3, (Malignant neoplasm of sigmoid colon). Just because the surgeon is scheduling the port removal for the completed chemotherapy doesn't ensure that the patient does not have current cancer. For example, radiation therapy doesn't require a port. Bottom line: Do not alter your surgeon's diagnosis based on your analysis of the situation. Check with the doctor if you have a question pertaining to the appropriateness of the diagnosis and figure out the final code accordingly. For more on this and for other specialty-specific articles to assist your general surgery coding, sign up for a good medical coding resource like Coding Institute.
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