Gastroenterology Coding Alert

" To select the correct ICD-9 diagnosis code for a colonic polyp, gastroenterology coders need to know whether the polyp is benign or malignant. Often, however, the pathology report (PR) will not use either term. Instead a pathological description will be used that points to the usual behavior of the polyp, and coders need to be able to translate those descriptions into benign and malignant.
 
The PR contains the definitive determination of a colonic polyp's behavior. To get the true picture of a polyp" you have to wait for the pathology report to come back " says Roberta Classen CPC CPC-H MCS-P financial manager Charleston (S.C.) Gastroenterology Specialists and a member of the AAPC national advisory board. "Gastroenterologists may imply what type of polyp it is in an operative report but they usually defer to the pathology report before making a recommendation."
Neoplasm Table Requires Information
Colonic polyps are growths of tissue that protrude from the bowel wall into the lumen. Some are neoplastic (from neoplasm) which means abnormal growth has occurred and there is potential for malignancy. Some are non-neoplastic which means that the growth consists of normal tissue with little or no potential for malignancy.
 
Coders should consult the neoplasm table in the ICD-9 Alphabetic Index to Diseases (Volume 2) when selecting a diagnosis code for a polyp. All diagnosis codes for neoplastic polyps will come from this table. Some of the diagnosis codes for non-neoplastic polyps will also come from this table. The neoplasms table requires the coder to have three pieces of information about the polyp to choose the correct code:
 
1. The part of the body. For malignant primary neoplastic polyps in the colon the specific site of the colon (traverse sigmoid ascending descending etc.) must be indicated. For all other behaviors the code descriptions make a general reference to the colon large intestine or digestive system.
 
2. The behavior of the polyp or its capacity to spread. Benign (noncancerous ) and malignant (cancerous) are two types of behavior. In addition a colonic polyp could be classified as uncertain (235.2) which means that it can't be determined if the polyp is malignant and the behavior is unpredictable and needs further investigation. It could also be unspecified (239.0) which means that the exact nature of the polyp must be determined by lab tests.
 
3. Whether the malignancy is primary secondary or in situ. A primary malignant colonic polyp (153.0-154.0) is one where the colon is the original site of the cancer. A secondary malignant colonic polyp (197.5) is one where the cancer [...]