Gastroenterology Coding Alert
Reflect Personal History With Z86.010
Question: If the physician does not state the type of polyp as adenomatous for a “surveillance colonoscopy,” should I report Z86.010 in addition to the Z12.11 or just the Z12.11? The physician’s note states “This 59-year-old gentleman is referred for surveillance colonoscopy after having polyps removed several years ago.”
West Virginia Subscriber
Answer: You should code Z86.010 (Personal history of colonic polyps). Code Z12.11 (Encounter for screening for malignant neoplasm of colon) describes average risk screening performed every ten years, so you shouldn’t report this code. You should not use Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) for endoscopic procedures.
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