Gastroenterology Coding Alert

Learn to draw the line between non-neoplastic and neoplastic polyps

When your gastroenterologist removes a colonic polyp, you will probably use a general ICD-9 code to describe the finding, or you can wait for the pathology report before you apply an ICD-9 of the highest specificity -- but don't catch yourself thumbing through your ICD-9 manual again.
 
Our experts categorize colonic polyps by non-neoplastic, neoplastic, and neoplasms and provide you with the corresponding diagnosis code.
 
Value to you: -Believe it or not, the pathology report will become important next year,- says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. -The proposed pay-for-performance measures will include a -Colon Polyp Surveillance- measure for the selection of the proper colonoscopy follow-up surveillance interval, thus adding a whole level of CPT codes.-

You Have to Know Some Vital Aspects

When selecting a diagnosis code for a polyp or snare removal polypectomy, you should look for three pieces of information:
 
1. Was this a polyp removal or a partial removal of a colon mass: Gastroenterologists use the snare removal technique to completely remove an abnormal growth or to partially remove a piece of a larger mass for pathologic identification. Look for the key words within the procedure description, including -polyp,- -lipoma- or -mass,- Weinstein says.
 
2. The polyp's general location: For polyps in the colon, documentation should indicate the specific colon site -- either from the rectal area (211.4, Benign neoplasm of the rectum and anal canal) or somewhere higher in the colon (211.3, Benign neoplasm of colon).
 
3. The colon: Sometimes your physician may find determining the colon cancer's primary site difficult because the cancer has already spread to neighboring tissue. In such cases, use 153.8 for -malignant neoplasm of contiguous or overlapping sites of colon whose point of origin cannot be determined,- the ICD-9 manual states.

How Path Report Affects Your Polyp Codes

If you are looking at the pathology report to determine a diagnosis code, you will notice several different types of polyps that can be either benign or malignant.
 
Check this out: The final pathology report will determine if a polyp is non-neoplastic or neoplastic. This differentiation is very important in selecting the proper time interval for a follow-up colonoscopy. Although most polyps do not usually turn cancerous, they may cause gastrointestinal problems such as bleeding and obstruction.
 
Types of non-neoplastic colonic polyps include:
 
Hyperplastic: Although they are not neoplasms, hyperplastic polyps in the colon most often occur in the rectal region, and you-ll usually report them with 211.4. Hyperplastic polyps found in any other region are reported with 211.3.
 
Mucosal: These are usually benign, and you should also report them with 211.3.
 
Inflammatory or pseudopolyps: These often occur in patients with inflammatory bowel disease or ulcerative colitis. Use 556.4 (Pseudopolyposis of colon) to report these polyps instead of a code from the neoplasm table.
 
Hamartomatous (also called Peutz-Jeghers polyps or a juvenile polyp): You should report these with 759.6 (Other and unspecified congenital anomalies; other hamartoses, not elsewhere classified), rather than a code from the neoplasms table.

Check Out These Neoplastic Polyp Classifications

Neoplastic polyps have specific classifications, too. They include:

Adenomatous polyps (APs): Gastroenterologists believe that most colorectal cancers arise from this polyp type, but not all adenomas develop into cancer. Because of the potential for malignancy, most insurers will reimburse follow-up and surveillance procedures for patients who have adenomatous polyps. Patients with APs are usually designated as having a history of colonic polyps (V12.72, Personal history of certain other diseases; diseases of digestive system; colonic polyps).
 
When the pathological finding is referred to as an -AP of the colon,- the behavior is benign, and your diagnosis code will be 211.3, Weinstein says. Instead of calling it an adenoma, the pathology report may also use one of the three subcategories of adenomatous polyps to describe it.   A tubular adenoma is a benign polyp. A villous adenoma of the colon is a carpet-like polyp that can have an uncertain behavior, and a more specific ICD-9 code is 235.2. A tubulovillous adenoma is a combination of the tubular and villous adenomas and is usually benign. Either ICD-9 code is acceptable, Weinstein adds.
 
A pathologist may also include a remark about the presence or degree of dysplasia, the earliest cancerous change, Weinstein says. Dysplasia can be low- or high- grade. -The additional information will not change your selection of an ICD-9 diagnosis code, but it will influence the selection of an interval for a follow-up colonoscopy for colon polyp surveillance,- Weinstein says.
 
Combination: Occasionally, a polyp is a combination of hyperplastic and adenomatous. Sometimes referred to as a serrated adenoma, you should treat this mixed polyp as if it were adenomatous. -It's also common for patients to have multiple polyps of different morphologies, such as hyperplastic polyps and APs,- Weinstein says. If the polyps have different diagnoses, you can report one for each type of polyp.
 
Adenocarcinomas: When an adenomatous polyp becomes cancerous, it is called an adenocarcinoma and is malignant. Sometimes a neoplastic polyp will contain an area of adenocarcinoma. In these reports the designation may be -carcinoma in situ,- Weinstein says.
 
Familial polyposis (also known as adenomatous polyposis coli): This is a genetic condition in which the patient has dozens or even hundreds of adenomatous polyps in the colon. Familial polyposis is benign. -It is almost certain, however, that colon cancer will develop from this condition, and, when it has turned malignant, it is generally referred to as adenocarcinoma in adenomatous polyposis coli,- Weinstein says.
 
Gastrinomas or carcinoids: These relatively rare neuroendocrine tumors are generally referred to as a benign or a malignant gastrinoma or carcinoid.

For Neoplasms, Look to These Types

Pathology reports identifying lipomas, osteomas and leiomyomas can appear to be typical colon polyps or neoplasms at the time of the procedure and lesion removal. These lesions are less common, but gastroenterologists can find them in the colon. They rarely become malignant.  Best bet: You should report them with 211.3.
 
Keep in mind: If the polyp is malignant, the pathology report may also provide information on whether it is primary, secondary or in situ. The gastroenterologist won't be able to tell you the polyp's status. You have to wait and look to the pathology report. Your patient's diagnosis can't be coded to the highest level of specificity if you report an -uncertain- code rather than waiting for the pathology report, says Linda Martien, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla.
 
Good advice: Once you-ve found the diagnosis code in the neoplasm table, verify it in the tabular list (Volume 1) of the ICD-9 manual. The code descriptions in the tabular list help identify which colon sites the code covers. For example, you should report a benign polyp in the rectosigmoid junction not as a benign colonic polyp but as a benign rectal polyp (211.4) -- even though the rectosigmoid junction is often lumped together with the colon in other ICD-9 descriptions.
 
You can code colon neoplasms with a specific region location within the colon (153.0-153.7), with a code for cancer in overlapping regions (153.8), or with a code for an unspecified location (153.9).