Question about diagnosis

[Sandy]

I was posting charges, I first read the conultation note and reviewed the diagnosis that the Doctor had listed. The diagnose listed was for 1) CA of the Colon, stage IV, 2) Coronary artery disease, 3) Congestive heart failure. But I noticed in the notes that Dr stated "has advanced carcinoma of the colon with liver metastasis." And that a different doctor was handling the the heart(CAD, CHF) issues. I think that the diagnose should be Primary CA of liver with CA of the colon 2nd, is this correct? Or because it is documented that way I shouldn't change it?

 

[Alicia Scott]

There are a few things to ask yourself here. The first would be what is the Consultation for? If the doctor is doing a consultation for the present Ca then that is the one you list first. A secondary Ca can be listed first but you use the secondary code. The pt has Ca of the colon that is now in the liver. If his consultation is about the colon the code for this goes first. Note: with "liver metastasis" means that this Ca is secondary so you don't call it Primary. Again, if the doctor is treating the liver Ca then it gets listed first even though it is a secondary code. The code itself tells the story that it is secondary now if it is placed first in the line up. On a side note primary Ca codes tend to start with a 1 and secondary Ca codes tend to start with a 2. Not always the case but most of the time.
Does that answer your question?