Colonoscopy biopsy without result to code

[ngastroent]

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.

 

[clarkmegan]

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.

I would use K63.89 to describe the mucosal irregularity and support the biopsy.

 

[ngastroent]

I would use K63.89 to describe the mucosal irregularity and support the biopsy.

Thank you for responding! Glad someone else confirmed my only guess!