Wiki Colonoscopy biopsy without result to code

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ngastroent

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Duluth, MN
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Patient came in for a screening colonoscopy. The doctor dictated there was a "mucosal irregularity on otherwise normal appearing ileocecal valve with villous appearance status post cold biopsies" along with a snare polyp removal in the ascending. Pathology states tubular adenoma for the polyp and "No evidence of dysplasia or malignancy" for the cold biopsy. So I've got:

45385-PT D12.11 and D12.2
45380-59 ---- Diagnosis code?

Would you use K63.9? That doesn't seem correct to me as nothing was found, but I don't know what else to use as there were no symptoms, just what he thought looked odd during the procedure.
 
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ngastroent said:
Patient came in for a screening colonoscopy. The doctor dictated there was a "mucosal irregularity on otherwise normal appearing ileocecal valve with villous appearance status post cold biopsies" along with a snare polyp removal in the ascending. Pathology states tubular adenoma for the polyp and "No evidence of dysplasia or malignancy" for the cold biopsy. So I've got:

45385-PT D12.11 and D12.2
45380-59 ---- Diagnosis code?

Would you use K63.9? That doesn't seem correct to me as nothing was found, but I don't know what else to use as there were no symptoms, just what he thought looked odd during the procedure.
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I would use K63.89 to describe the mucosal irregularity and support the biopsy.
 
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