Coding Tip: Diagnosis Coding-Colon Polyps and History of Colon Polyps
This Coding Tip was updated on 3/6/2018
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
In ICD-9-CM it was easy to code a colon polyp or history of colon polyp as there were only one or two codes to report unless malignancy was found. In ICD-10-CM that is not the case as there is such specificity for the type of polyp. What is seen most of the time documented in the records is hyperplastic polyps of the colon/rectum.
Hyperplastic colon polyp-these polyps have little to no malignant potential/they are not neoplastic in nature. They are serrated polyps. These polyps are typically found in the distal colon and rectum. Follow up is not as often for these types of polyps.
Adenomatous colon polyp-these polyps have a high potential for malignancy but most times are benign during the initial finding. These are adenomas (tubular, tubulovillous, villous, and sessile serrated.) Follow up is needed for adenomatous polyps more often than hyperplastic polyps.
How do we code history of hyperplastic colon or rectal polyp?
Z87.19, Personal history of other diseases of the digestive system would be reported when hyperplastic colon or rectal polyp is documented. It would not be appropriate to report Z86.010, personal history of colonic polyps because the title of this subcategory in ICD-10 is personal history of benign neoplasm. Since the hyperplastic polyps are not neoplastic in nature, this code would be inappropriate.
How do we code history of colon or rectal polyp without further clarification of the type of polyp (hyperplastic or adenomatous)?
From a recent letter sent to AHA Coding Clinic 030518 Ref. #50024171.118:
“Code Z86.010, Personal history of colonic polyps, should be assigned when ‘history of colon polyps’ is documented by the provider. History of colon polyp specifically indexes to code Z86.010.” “AHA Coding Clinic, First Quarter 2017, there is not an Index entry for rectal polyps. Therefore, code Z87.19, Personal history of other diseases of the digestive system is assigned for history of rectal polyp.”
–colon polyp Z86.010
How do we code history of colon or rectal polyp further clarified as adenomatous polyps?
Z86.01, Personal history of benign neoplasm would be reported. The code will be further specified depending on the colon (Z86.010) or rectum (Z86.018).
How do we code current hyperplastic colon polyp?
K63.5, Polyp of colon is used for documented hyperplastic colon polyp regardless of the site within the colon.
How do we code current adenomatous colon/rectal polyp?
A code from Category D12- would be reported. The site of the polyp will provide a more specific code (D12.0-9).
How do we code current colon/rectal polyp without any further documentation of specificity?
A colon polyp without any further specificity is coded to K63.5 (this is the default code for colon polyp). Rectal polyp documented without any further specificity is coded to K62.1.
For coding purposes, the coder should code to the highest degree of certainty at the time of code assignment. Be sure and check with the facility to determine what reports should be available prior to code assignment.
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, First Quarter 2017, Pages: 14-17
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, Second Quarter 2015, Pages: 14-15
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
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Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
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