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 [...]