Gastroenterology Coding Alert

Question: Our gastroenterologist documented a polyp removal but we aren't sure how to determine which diagnosis code to report. There are too many to choose from – can you advise?

Codify Subscriber

Answer: When attempting to pinpoint a diagnosis code for a polyp, you'll want to review the documentation carefully. First, determine the polyp's specific location. ICD-10 codes are very location specific, and even for the colon region there are six polyp codes (D12.0 - D12.5) based upon whether the polyp is in the cecum, appendix, ascending colon, transverse colon, the descending colon, or the sigmoid colon. You should use the non-specific polyp code D12.6 (Benign neoplasm of colon, unspecified) only as a last resort.

As another example, for the rectal region, the codes expand to D12.7 (Benign neoplasm of rectosigmoid junction), D12.8 (Benign neoplasm of rectum), and D12.9 (Benign neoplasm of anus and anal canal).

You should also ensure that the doctor did, in fact, remove a polyp. 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."

In cases of colon cancer, sometimes your physician may find it difficult to pinpoint the cancer's primary site because the cancer has already metastasized to neighboring tissue. In such cases, you can report code C18.8 (Malignant neoplasm of overlapping sitesof colon) or C18.9 (Malignant neoplasm of colon, unspecified).

Keep in mind: The answer above applies when the pathology is known, but without pathology known, there is a generic code K63.5 (Polyp of colon) in the ICD-10 hierarchy, as well as code K62.1 (Rectal polyp) which is appropriate for a hyperplastic (non-adenomatous) polyp in the rectum.