|April 2004 · Vol. 16, No. 4
5-month follow-up after cancer resectionMELANIE
RN, CPC, MA
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of
Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects
the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter,
check with your individual payer.
Q Five months after surgery to remove endometrial cancer, a patient came in for a follow-up visit. Since the 90-day follow-up period had passed, we billed for an office visit. The diagnostic codes used were V10.42 (personal history of endometrial cancer) and V76.2 (special screening for malignant neoplasms, cervix) for Pap screening. Because ICD-9 marks V10.42 as a secondary diagnosis, however, I fear this may be incorrect. Is it?
A Before answering this question, we need to better define the situation by making some assumptions. First, I will assume that the surgery involved removing the uterus as well as the cervix.