Sharpen Your Colonic Polyp Vocabulary With These Tips

Not all patients who present to the office with colon polyps will be diagnosed with colon cancer. This second-leading cause of cancer-related deaths in the US usually begins as small, benign adenomatous lump, and becomes cancerous overtime.

Colon cancer, or colorectal cancer as it’s regularly known, is a cancer which starts in the large bowel portion of the gastrointestinal (GI) system. Because it comes in many forms and symptoms, coding the definitive diagnosis might be risky. Guard your practice’s deserved dollars with these 3 tips.

1. Don’t Go Looking For ‘Benign’, ‘Malignant’

Whether or not you’re dealing with a full-blown colorectal cancer, you should be looking at the different terms used to describe benign or malignant colonic polyps. Some of these include:

  • Adenomas including tubular adenomas and tubulovillous adenomas
  • Hyperplastic polyps
  • Inflammatory polyps
  • Familial adenomatous polyposis, a rare hereditary disorder that causes hundreds of polyps in the lining of the colon beginning in the teenage years. If this is left untreated, the patient becomes high risk to develop colon cancer.
  • Hereditary nonpolyposis colorectal cancer, a hereditary disorder that causes an increased risk of developing colon cancer.

But first, you have to accomplish the task of determining — without a doubt — if a polyp is benign or malignant. If you think you would find the clues in the pathology report (PR), think again. Usually, the PR will not use the term “benign” or “malignant.” However, it will use a description that points to the usual behavior of the polyp. It’s up to you to interpret those descriptions into benign or malignant.

Experts advise that you always wait for the pathology report to come back before deciding on a particular ICD-9. Even the gastroenterologists, themselves, usually defer to the pathology report before making a recommendation.

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Diagnosis Coding: G Codes Are Your Key To Coding Correct High Risk Colonoscopy

Get your hemorrhoid report right and stress-free in a snap. We’ll tell you the difference between internal and external hemorrhoids, but you can learn more from this sample physician’s report:

PREPROCEDURE DIAGNOSIS: History of colon polyps and partial colon resection, right colon.

POSTPROCEDURE DIAGNOSES:

  1. Normal operative site.
  2. Mild diverticulosis of the sigmoid colon.
  3. Internal hemorrhoids.

PROCEDURE: Total colonoscopy.

PROCEDURE IN DETAIL: The 60-year-old patient presents to the office to be evaluated for the preprocedure diagnosis. The patient also apparently had an x-ray done at the hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet’s, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some internal hemorrhoids.

RECOMMENDATIONS: Repeat colonoscopy in three years.

Let Location Guide You

You can easily identify external hemorrhoids (455.3-455.5) because of its place of appearance. This type of hemorrhoid has a fleshy growth and occurs around the anus — specifically, outside the anal verge which is at the distal end of the anal canal. On the other hand, internal hemorrhoids (455.0-455.2) occur inside the...

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