General Surgery Coding Alert

Question: We have a case in which the surgeon performed a screening colonoscopy, but found and removed a polyp in the transverse colon. The pathology report identified the polyp as a tubular adenoma. What is the correct diagnosis coding for the case?

Ohio Subscriber

Answer: Although the typical advice for a surgical case is to report just the pathology diagnosis, doing so is not appropriate in this situation. Because this is a screening colonoscopy that turned diagnostic when the surgeon removed a polyp, you need to capture that information with diagnosis codes. The diagnosis coding in this case has a big impact on how payers cover the procedure and how much the patient will have to pay.

Do this: List first the screening code Z12.11 (Encounter for screening for malignant neoplasm of colon), and then list the final diagnosis D12.3 (Benign neoplasm of transverse colon).

More: You should also know that you’ll need to use a modifier with the procedure code to indicate that the surgeon initiated this as a preventive service — a screening procedure turned diagnostic. For a Medicare beneficiary, append modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure). For most commercial payers, you’ll need to use modifier 33 (Preventive services).