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Gastroenterology Coding Alert

You Be the Coder:

Look Closely at the Final Path Report Before Coding a Polypectomy

Published on Mon Jul 21, 2014

Question: Should we wait for the final pathology report before coding a polypectomy?

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Answer: In the past the answer might have gone either way but going forward the answer is probably  yes. It is always better to wait for the final path report to see if polyp is benign or malignant certainly before determining the need for other treatment and before determining the proper interval for the next surveillance colonoscopy. Whether or not you’re dealing with a full-blown colorectal cancer, you should look at the different terms used to describe benign or malignant colonic polyps. Some of these include:
 
Adenomas including tubular adenomas and tubulovillous adenomas
  • Hyperplastic polyps
  • Inflammatory polyps
  • Familial adenomatous polyposis, a rare hereditary disorder that causes hundreds of polyps in the lining of the colon beginning in the teenage years. If this is left untreated, the patient becomes high risk to develop colon cancer.
  • Hereditary nonpolyposis colorectal cancer, a hereditary disorder that causes an increased risk of developing colon cancer.
  • But first, you have to accomplish the task of determining — without a doubt — if a polyp is benign or malignant. If you think you would find the clues in the pathology report (PR), think again. Usually, the PR will not use the term “benign” or “malignant.” However, it will use a description that points to the usual behavior of the polyp. It’s up to you to interpret those descriptions into benign or malignant.
Important: Experts advise that you always wait for the pathology report to come back before deciding on a particular ICD-9. Even the gastroenterologists, themselves, usually defer to the pathology report before making a recommendation.  “One of the quality measures your physicians will be reporting to CMS deals with the whether the patient was advised to return at the appropriate interval following a polyp removal.  They will want to get this interval correct based on the actual pathology report rather than their guess about the polyp type,” says Dr. Michael Weinstein, MD.

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