tci Part B Insider - 2012 Issue 10

Reader Question: Pathology Findings Lead Dx

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...

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