General Surgery Coding Alert

Question: I’m uncertain about the right diagnosis code to use for a polyp removal surgery that our general surgeon recently conducted. The patient record describes the mass as a “polyp located high in the colon.” I’m nervous about using an unspecified code, but none of the other D12.- codes seem appropriate.

Washington Subscriber

Answer: hen coding polyp removal, it’s crucial to have precise information about the location of the polyp. In this situation, you’ll need to query the provider for more detailed documentation.

There is nothing inherently wrong with reporting D12.6 (Benign neoplasm of colon, unspecified), but this code should only be used if the provider does not have further details. The provider in the above scenario has the location but didn’t use the technical term for the exact location. The ICD-10-CM codes are location-specific, so given that this information is likely just a query away, D12.6 may not be correct.

As you have probably noticed, there are six polyp codes just for the colon region:

• D12.0 (Benign neoplasm of cecum)
• D12.1 (… appendix)
• D12.2 (… ascending colon)
• D12.3 (… transverse colon)
• D12.4 (… descending colon)
• D12.5 (… sigmoid colon)

Anatomy refresh: The journey of the colon begins with the cecum, located in the lower right abdomen, and the appendix is attached to it. Moving upward, the colon enters the ascending colon, which runs vertically on the right side of the abdomen. The colon then takes a bend, transitioning into the transverse colon, which stretches horizontally across the abdomen. Another bend occurs as the colon turns downward, forming the descending colon on the left side of the abdomen. Finally, the colon curves inward, forming the sigmoid colon, which connects to the rectum.

Despite your knowledge of colon anatomy, it’s crucial not to make assumptions about the specific part of the colon the gastroenterologist is referring to. Always seek clarification from the provider if the documentation isn’t clear. Also, remember that if the pathology report is still pending, you can use the general code K63.5 (Polyp of colon), which isn’t specific to any region. “Remember that the best practice is to await the pathology report for definitive coding and lower chance of denial,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.