Pathology/Lab Coding Alert

Question: When the surgeon performs a screening colonoscopy, finds a polyp in the right colon, removes it, and sends it to our pathologist who diagnoses cancer, what ICD-9 code should we use for the pathology report? Should we use the screening code, the final diagnosis, or both?

Nevada Subscriber

Answer: The correct diagnosis code for the pathology report is the findings -- 153.6 (Malignant neoplasm of ascending colon). The pathologist is not performing a screening exam --- he receives a polyp, which serves as a "sign or symptom" of disease, effectively making this a diagnostic exam from the perspective of the pathologist. That means the pathologist should report the ICD-9 code that corresponds to his findings as the primary diagnosis on the claim, according to The ICD-9-CM Official Guidelines for Coding and Reporting, even though the surgeon obtained the tissueduring a screening procedure.

Non-malignant solution: For a confirmed polyp that is benign, the pathologist should assign 211.3 (Benign neoplasm of colon). If the pathologist cannot determine a definitive diagnosis for the lesion, you should report the sign or symptom as the primary diagnosis, such as 569.9 (Unspecified disorder of the intestine).

Surgeon's coding may differ: Medicare instructs the physician performing the screening colonoscopy to list the appropriate screening diagnosis code first, such as V76.51 (Special screening for malignant neoplasms, Colon). The surgeon should list the findings, such as 153.6, as the secondary diagnosis. You can read more about this topic at www.cms.gov/MLNMattersArticles/downloads/se0746.pdf.