Wiki J-Pouch with polyp diagnosis help!!

[jodielonkoski]

I have a patient who had a total colectomy and has a J-pouch. They had a pouchoscopy which showed polyps that were removed, what ICD code would I use for polyps of an ileal pouch? The patient does not have any of their colon or rectum so I cannot use those codes, and the area of intestine is technically the ileum, small intestine. There is no code for polyp of the small intestine, looking for guidance from anyone who has coded this before.

 

[danachock]

Hello jodielonkoski,
I am reviewing your question and I completely understand and feel your pain here.
Polyp of colon K63.5 isn't appropriate, clearly neither is K62.1 (polyp of rectum) or K31.7 (polyp of stomach & duodenum).
This is my rationale here. We know that pouchitis occurs for patients similar to this one. That is not the interpretation here of course.
Therefore, I reviewed that section of our ICD book for this unique case, and I am leaning on K91.858 for diagnosis assignment.
Would you mind taking a peek at your ICD book to see if you agree or not, please?
Thanks,
Dana

 

[pookergirl]

Was the polyp on path found to be a benign adenoma? If so, I would use the K51.858 but I would also add D36.7 Benign neoplasm of other specified sites as well.