ICD 10 Coding Alert
Remember, You Can Query Before Using Unspecified Codes
Question: I’m trying to select the most accurate diagnosis code for a polyp removal, but I’m not sure which to use. The patient record describes the mass as a “polyp located high in the colon.” I’m wary of using an unspecified code, but none of the other D12.- codes seem appropriate. Minnesota Subscriber Answer: When coding polyp removal, knowing the exact location is essential to coding to the highest specificity. In this situation, you’ll need to ask the provider for more detailed documentation. There is nothing inherently wrong with reporting D12.6 (Benign neoplasm of colon, unspecified), but this code should only be used if the provider does not have details. The provider in the above scenario does have the location, they just didn’t use the technical term for the exact location. The ICD-10-CM codes are location-specific, so given that this information is likely just a query away, D12.6 would not be correct. As you have probably noticed, there are six polyp codes just for the colon region: Anatomy refresh: The colon starts with the cecum in the lower right abdomen, and the appendix projects from the end. From the cecum, the colon then moves upward, and that section is called the ascending colon. It then bends, running across the abdomen, which is called the transverse colon. It bends again toward the lower left abdomen, and that section is called the descending colon. The sigmoid colon is where the colon then curves then turns into the rectum. Even if you’re familiar with colon anatomy, you never want to assume which part of the colon the gastroenterologist referred. Always ask the provider for clarification if the documentation is unclear. Note also that if the pathology report isn’t back, the generic polyp code K63.5 (Polyp of colon) could be used, which is not region-specific.
Related Articles
ICD 10 Coding Alert
- Anesthesia Coding:
Look at the Big Picture for 2023 Updates
Don’t miss the new options for endometriosis. Anesthesia coders see myriad diagnoses, so it’s crucial [...] - Cardiology Updates:
Find Out About Aortic Aneurysm Coding Changes
Hint: You’ll see new code I20.2 for refractory angina pectoris. The Centers for Medicare & [...] - Pediatrics Update:
Count Newborn and Perinatal Code Changes in Your Update Repertoire
Hint: Some otherwise familiar codes may require an additional character come Oct. 1. Pediatric coders [...] - You Be the Coder:
If Suspected Tumors Don’t Materialize, Try This
Question: This patient is at high risk for stage 1 urothelial cell carcinoma and is here [...] - Reader Questions:
Beware This Qualifying Note for Acute Pulmonary Edema Code
Question: I have documentation that lists the patient’s diagnosis as pulmonary edema, but the documentation doesn’t [...] - Reader Questions:
Cement This Difference Between ‘Unspecified’ and ‘Other’
Question: What is the difference between E78.5 (Hyperlipidemia, unspecified) and E78.49 (Other hyperlipidemia)? Oregon Subscriber Answer: Code [...] - Reader Questions:
Remember, You Can Query Before Using Unspecified Codes
Question: I’m trying to select the most accurate diagnosis code for a polyp removal, but I’m [...]
