Pathology/Lab Coding Alert

Question: When the surgeon performs a screening colonoscopy, finds a polyp in the right colon, removes it, and sends it to our pathologist who diagnoses cancer, what ICD-9 code should we use for the pathology report? Should we use the screening code, the final diagnosis, or both?Nevada SubscriberAnswer: The correct diagnosis code for the pathology report is the findings -- 153.6 (Malignant neoplasm of ascending colon). The pathologist is not performing a screening exam --- he receives a polyp, which serves as a "sign or symptom" of disease, effectively making this a diagnostic exam from the perspective of the pathologist. That means the pathologist should report the ICD-9 code that corresponds to his findings as the primary diagnosis on the claim, according to The ICD-9-CM Official Guidelines for Coding and Reporting, even though the surgeon obtained the tissueduring a screening procedure.Non-malignant solution: For a confirmed polyp that is benign, the pathologist should [...]