Pathology/Lab Coding Alert

Tip: Dx drives follow-up frequency rules

With the implementation of pay-for-performance, reimbursement for repeat colonoscopy depends on frequency rules linked to the diagnosis. That's why now, more than ever before, you need to accurately translate the pathology report language into ICD-9 codes.

From polyps to colon cancer, follow our experts- advice for assigning colon-specimen diagnoses.

Don't be fooled: Although your first stop is often the neoplasm table, you need to be familiar with these non-neoplastic polyps that you won't find in the table:

- Inflammatory or pseudopolyps: These often occur in patients with inflammatory bowel disease or ulcerative colitis. Use 556.4 (Pseudopolyposis of colon) to report these polyps instead of a code from the neoplasm table.

- Hamartomatous polyps: Also called Peutz-Jeghers polyps or juvenile polyps, you should report these with 759.6 (Other and unspecified congenital anomalies; other hamartoses, not elsewhere classified), rather than a code from the neoplasm table.

Check Out the Neoplasm Table

If the colon specimen is not pseudopolyps or hamartomatoses, you-ll need to start with the neoplasm table to find the condition. ICD-9 distinguishes neoplasms as benign, malignant, of uncertain behavior, or carcinoma in situ. Look up -neoplasm- in the ICD-9 Index to Diseases (Volume 2), and then find -intestine, large- in the neoplasm table.

Good advice: Once you-ve found the diagnosis code in the neoplasm table, verify it in ICD-9's tabular list (Volume 1). The code descriptions in the tabular list help identify which colon sites the code covers.

For example: You are trying to find the code for a benign polyp in the rectosigmoid junction. The neoplasm table lists 211.3 for benign colonic polyp and 211.4 for benign rectal polyp. You have to turn to the tabular list to find out which code is correct. A note under 211.3 states, -excludes rectosigmoid junction (211.4),- so you know that 211.4 is the correct code for your specimen.

Learn Common Terminology

Because the pathology report may use many terms that you won't find in ICD-9, follow our experts- advice about how to classify these terms. For tissue from the colon or rectum, you should be familiar with the following classifications:

- Mucosal polyps: These are usually benign, and you should report them as 211.3 (Benign neoplasm of colon), according to Pamela Younes, MHS, HTL (ASCP), CPC, PA (ASCP), assistant professor at Baylor College of Medicine in Houston.

- Hyperplastic polyps: Hyperplastic polyps are also benign, so you should also report them as 211.3. Hyperplasia can also occur in the rectal region, which you should submit as 211.4 (Benign neoplasm of rectum and anal canal), Younes says.

- Adenomatous polyps (APs): Most colorectal cancers arise from this polyp type, but not all APs develop into cancer. Because of the potential for malignancy, most insurers will reimburse follow-up and surveillance procedures for patients who have adenomatous polyps.

Instead of using the term -adenomatous polyp,- the pathology report may use one of the three following subcategories to describe the findings:

- Tubular adenoma -- this is a benign polyp that you should report as 211.3 in the colon.

- Villous adenoma of the colon -- this describes carpet-like polyps that are benign (211.3) but can lead to cancer. If the pathology report mentions other biopsy conditions, such as high-grade dysplasia associated with the villous adenoma, you should report 235.2 (Neoplasm of uncertain behavior of stomach, intestines, and rectum), Younes says. Select a different appropriate code if the report indicates the villous adenoma is malignant (see possible malignant diagnoses below).

- Tubulovillous adenoma -- this is a combination of the tubular and villous adenomas that is usually benign. Either ICD-9 code (211.3 or 235.2) is acceptable, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

- Combination: Occasionally, a polyp is a combination of hyperplastic and adenomatous. Sometimes referred to as a serrated adenoma, this mixed polyp is treated as if it were adenomatous.

- Familial polyposis: Also known as adenomatous polyposis coli, this is a genetic condition in which the patient has dozens or even hundreds of adenomatous colonic polyps. Familial polyposis is benign, and you should report it as 211.3. -It is almost certain, however, that colon cancer will develop from this condition,- Weinstein says. If the condition becomes malignant, the physician may refer to it as -adenocarcinoma in adenomatous polyposis coli,- and you should code it as a colon malignancy.

- Other benign lesions: Pathology reports identifying lipomas, osteomas and leiomyomas can appear to be typical colon polyps or neoplasms at the time of the procedure and lesion removal. These lesions are less common, but physicians can find them in the colon. They rarely become malignant. Best bet: You should report them with 211.3 or 214.8 (Lipoma; other specified sites).

Watch for multiple diagnoses: -It's common for patients to have multiple polyps of different morphologies, such as hyperplastic polyps and APs,- Weinstein says. If the polyps have different diagnoses, you can report different ICD-9 codes for each polyp type.

Don't miss the V code: Following a finding of adenomatous polyps, the physician will usually designate that the patient has a history of colon polyps (V12.72, Personal history of certain other diseases; diseases of digestive system; colonic polyps). You-ll need this V code to show medical necessity for follow-up surveillance.

Know Malignancy Lexicon

The pathology report might refer to several conditions that you-ll code as a malignancy from the ICD-9 neoplasm table. You should be familiar with the following colon cancer terms:

- Carcinoma in situ: Sometimes a neoplastic polyp will contain an area of adenocarcinoma. In these pathology reports, the designation may be carcinoma in situ, Weinstein says, which you should report as 230.3 (Carcinoma in situ of colon). Or you may use 230.4 for the rectum or 230.5 for the anal canal if either code more clearly describes the polyp location.

- Intramucosal carcinoma: This describes the findings of adenocarcinoma only in the mucosa without invasion of underlying tissue. You should report these findings as carcinoma in situ (230.3), Younes says.

- Adenocarcinoma: When an adenomatous polyp becomes cancerous, it is a malignant neoplasm called an adenocarcinoma. How you report the condition depends on whether the cancer is primary or secondary. You-ll also need to know the tumor location in the colon to select the proper code. See -Location, Location, Location Dictates Colon Cancer Codes- in this issue to learn more about coding for these colon malignancies.

- Carcinoids: These relatively rare neuroendocrine tumors may occur as benign or malignant tumors in the colon. You should choose the proper code based on the behavior (benign, malignant or uncertain) and location.