Wiki Benign colonic mucosa diagnosis

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Bernadette10

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What should I use for the diagnosis for this?
Screening colonoscopy:
A rectal examination was performed. The Olympus pediatric colonoscope was inserted into the rectum and advanced under direct vision to the cecum, which was identified by the ileocecal valve and appendiceal orifice. The quality of the colonic preparation was good. A careful inspection was made as the colonoscope was withdrawn, including a retroflexed view of the rectum; findings and interventions are described below.

FINDINGS: -hemorrhoids (internal and external), Moderate in size
-polyp(s) - #1, 5 mm in size, Flat, the transverse colon, removed by hot biopsy and sent for pathology

Path report: Transverse colon polypectomy-Colonic mucosa with no significant histopathologic abnormalities.

I would think this polyp would not be coded if it's only benign colonic mucosa, but it was removed, so if I code only Z12.11, would 45384 be covered? Would the polyp be coded as benign neoplasm D12.3? When I look under polyp/colon/transverse, that's what it leads to.
 
benign colonic mucosa diagnosis

Another coder told me to code this as benign D12.3 since it was removed as a polyp. If the path report had shown hyperplastic polyp, then it would be K63.5.
 
Coding D12.3 would not be appropriate since the pathologist did not document any neoplastic process in the tissue. 'Colonic mucosa' are normal cells, not benign neoplasms.

K63.5 would be more appropriate since the physician performing the procedure did document that it was a polyp.
 
I agree with Thomas , but what do we code for that same benign mucosa dx when it is not a polyp?. Do we use k63.89, or k63.9 or just code the symptoms?
 
Our consulting service recommends using the K63.89 to help justify why the biopsies were taken even when pathology was normal. I wouldn't think 45384 would be covered w/just the Z code.
 
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