# icd-9 coding pathology



## cbrookshire (Sep 11, 2014)

i've been coding pathology for a bit now and i'm preparing for my cpc next friday.
here is example before i ask my question:
Clinical Note: A. 30 cm polyp
                    B. 60 cm polyp, trap #1
Source: Colon
Operative Diagnoisis: Personal history of colonic polyps
                                Polyp
Pathology Diagnosis: A. Hyperplastic polyp; no evidence of adenomatous change.
                               B. Hyperplastic polyp; no evidence of adenomatous change.

I coded these both with 211.3. I was told/taught to code the diagnosis. So thats what I've been doing. Claims have been paid. No problem.

Received a call from insurance company (one of several lately) telling me the codes are incorrect and could I change.
So my question is - after going back and looking through my books and not finding what I need - 
#1 - is this incorrect? 
#2 - if incorrect, should I only use the V code?
#3 - if incorrect, should I use the V code as primary and the 211.3 as secondary?
Also, should I be using V code if ANY specimen is submitted for a routine cancer screen? 
I'd really like to get this straightened out for myself before my exam next week. 
Thank you in advance.
Cathy B.
Manton, MI
Be groovy!


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## mitchellde (Sep 11, 2014)

If this was a screening you must use the V code for screening 1st listed with any finding secondary.  If was diagnostic for a symptomatic complaint then you may code either the symptom or the finding but not both.


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## cbrookshire (Sep 11, 2014)

and should i do the same if it states "personal history of"?
thank you thank you.


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## mitchellde (Sep 11, 2014)

It depends on the reason for the study if it is screening then yes,  if it is a surveillance die to the history then use the V code for follow up first listed and the history of second


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## cbrookshire (Sep 11, 2014)

it just states - personal history of colonic polyp; polyp

so in this case, i would code the dx first and then history of?


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## Denise0728 (Sep 12, 2014)

*Pathology Coding - ICD 9*

If you are taking your CPC; keep in mind that is out patient, professional based coding.  

This all I could find in the guidelines for coding from a path report:

(Section III, B. Abnormal Findings)  "Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the abnormal finding should be added."


In my mind; it was the attending/treating physician who could diagnosis the patient.  Therefore; in the example that you have given I see the diagnosis as "Personal history of colonic polyps"


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