Pathology/Lab Coding Alert

Question: I'm billing for the pathologist's evaluation of a colon polyp under the following circumstances:
  Preoperative diagnosis: Family history of colon cancer
  Specimen: Right transverse colon polyp
  Final diagnosis: Right transverse colon polyp, no pathologic change.
 
The surgeon's office informed us that there were no signs or symptoms, and that the reason for the surgery was the family history of colon cancer. We reported the diagnosis as V16.0, and Medicare denied the charge for the pathologist's service. How should we code this?

Minnesota Subscriber Answer: The fact that the patient has a polyp is the "sign or symptom" that you should code. The correct ICD-9-CM code for a colon polyp is 211.3 (Benign neoplasm of colon). You can confirm this by looking up "Polyp, colon" in ICD-9-CM Volume 2 in the alphabetic index. List the family history of colon cancer (V16.0, Family history of malignant neoplasm; gastrointestinal tract) as a secondary diagnosis. If the patient had a family history but no polyp, the pathologist would not have the specimen to examine.
 
That being said, the pathologist's description is confusing at best. "No pathologic change" indicates normal colon tissue, but the specimen is a polyp, which is not normal tissue. You should ask the pathologist to clarify if the final diagnosis is colon polyp, meaning that you should report 211.3 as the final diagnosis.
 
You should change the diagnosis from 211.3 if the pathologist provides a more definitive diagnosis after performing the examination, and you have that information available at the time of billing. For example, if the pathologist diagnosed the specimen as a villous adenoma of the colon, you would change the ICD-9 code you report to describe the final diagnosis - 235.2 (Neoplasm of uncertain behavior of stomach, intestines, and rectum).
 
In either case, you should report the pathologist's work as 88305 (Level IV - Surgical pathology, gross and microscopic examination, polyp, colorectal).