Wiki Coding from Pathology results after Colonoscopy

[pookergirl]

I'm looking for some expert advice on a scenario I often come across in facility coding for a GI office. Patient had colonoscopy for rectal bleeding. Postop dx was "same and diverticulosis, multiple small erosions/ulcerations in proximal colon." Pathology findings were as follows:

DIAGNOSIS

ASCENDING COLON, BIOPSIES: - PATCHY CHRONIC ACTIVE COLITIS WITH FOCAL EROSIVE CHANGE. NEGATIVE FOR GRANULOMATA OR DYSPLASIA. SEE COMMENT.

"The sampled mucosa is heterogeneous. Much of the mucosa contains non-specific reactive change. There are some changes of chronicity, however, with focal bifid crypts, and basilar lymphoplasmacytosis. Acute inflammatory changes consist of focal acute cryptitis, a couple ruptured acutely inflamed crypts, and focal erosive-type change. A microscopic examination is performed. Multiple tissue levels were reviewed. Colonic mucosa alternates from focal mucosa containing erosive change to mucosa containing features consistent with a chronic active colitis with acute cryptitis, crypt abscess formation, and architectural distortion with basilar lymphoplasmacytosis to some relatively normal-appearing mucosa containing non-specific reactive and regenerative change."

I've coded the diverticulosis w/rectal bleeding, but my question is, because of the description of inflammation and crypt abscess formation and patient's history of rectal bleeding, using the coding pathway w/diagnosis of colitis, it is coding out to ulcerative colitis (UC) with abscess formation and UC with rectal bleeding, but I'm questioning whether I can use these diagnoses without the provider specifically stating "ulcerative colitis" anywhere. I am unable to find an answer online to this question and would appreciate feedback from a veteran GI coding professional. I could just code the diverticulitis with rectal bleeding and colitis unspecified as that as "chronic" and "hemorrhage" are nonessential modifiers.

Thank you in advance for the guidance.

 

[amla12]

Hi, I'm not an expert in terms of certification, but I do have 16 years of GI billing experience. I would go with 'colitis unspecified' unless the doctor has specifically diagnosed UC. When findings point to IBD, pathology reports tend to present these in the context of the full clinical picture (including serology results).