Revenue Cycle Insider

Question: A patient with a history of adenomatous colon polyps came in for a screening colonoscopy. The report states that the gastroenterologist did not find any polyps during the colonoscopy. What diagnosis codes should I report for the procedure?

Georgia Subscriber

Answer: This is a unique situation that requires careful review of the provider’s documentation. Based on the information you’ve provided, you’ll report the following ICD-10-CM codes:

• Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm)
• Z86.0101 (Personal history of adenomatous and serrated colon polyps)

Code Z86.0101 was added to the ICD-10-CM code set on Oct. 1, 2024, but the code should not be used as a primary diagnosis code. According to the ICD-10-CM Official Guidelines, section I.C.21.c.4, “Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.”

The guidelines continue to state that the reason for the encounter “should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).”

This means you’ll assign Z09 as the primary diagnosis code followed by Z86.0101 as the secondary diagnosis code.

Of course, it is best to check with the patient’s payer to confirm what codes to assign and how to sequence the diagnosis codes in situations such as the one you’ve mentioned.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC