General Surgery Coding Alert

Question: We’re coding an op report for an excised polyp from the rectosigmoid junction that the surgeon identifies as a “colon polyp,” but the pathology report identifies as “hyperplastic polyp.” What is the correct diagnosis code for this case?

Florida Subscriber

Answer: You should base the diagnosis code on the pathologist’s final diagnosis, not the surgeon’s designation, if they differ.

The correct code for a hyperplastic polyp of the rectosigmoid junction is D12.7 (Benign neoplasm of rectosigmoid junction). For hyperplastic polyps, the correct subcategory is D12.x with the fourth character (0 to 6) specifying the location.

You should avoid using the less-specific code, K63.5 (Polyp of colon), even though that’s what how the surgeon identified the specimen.