Gastroenterology Coding Alert

Question: My gastroenterologist removed a polyp from the rectosigmoid area. Which ICD-9 code should I use -- a colon polyp or a rectal polyp?

Tennessee Subscriber

Answer: You should consider the rectosigmoid area part of the rectum and not the intestine. Your coding options are 154.0 (Malignant neoplasm of rectosigmoid junction), which includes "rectosigmoid junction" in its description, and 211.4 (Benign neoplasm of rectum and anal canal).

Good idea: Keeping in mind the rectosigmoid area is part of the rectum can help your claim when your gastroenterologist performs multiple endoscopies.

For instance, if your gastroenterologist performs a polypectomy with snare in the ascending colon (45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and then does a polypectomy by hot biopsy from the rectosigmoid area (45384-59, ...with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery-Distinct procedural service), you should report two separate codes. These procedures took place in separate sites.

Remember: You should also use different diagnosis codes for each of the procedure codes.

Take away point: Always check all endoscopy reports and pathology reports for the location of all removed lesions prior to claim submission.