tci General Surgery Coding Alert - 2010 Issue 12

Reader questions: 153.3 Vs. V10.05 -- Get the History Right

Question: We have a patient who had a colon resection for cancer over six months ago. Two months following surgery, he had a Mediport inserted for chemotherapy. The patient has completed the course of treatment and comes to our surgeon's office to discuss when to schedule the Medi-port removal because he is in remission. Our surgeon also inspects the incisions from the initial resection and the Medi-port insertion. The surgeon dictates the diagnosis for the service as "colon cancer" even though he's scheduling the Medi-port removal because the colon cancer treatment is complete. Shouldn't the diagnosis be "history of...

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