Wiki K63.5 vs. D12.

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After a recent coding seminar several coders in my organization are debating the usage of the polyp codes. If we do not have the pathology report findings when billing for the 45385/45380, do we use the K63.5 or the approriate D12 code based on the location of the polyp. The seminar speaker said to use K63.5. However, now one of our long-term coders in the organization disagrees and says that it depends on LCDs and that in North Carolina we can use the D code without the pathology confirmation. I don't see where it should matter what state you are in. If you don't have pathology confirm the nature of the polyp prior to billing, I would think you have to use the K63.5 like the seminar speaker said. Thoughts????
 
I personally agree with K63.5, as you cannot diagnosis a patient with a benign tumor on the basis of only a polyp and location documented. Not unless, it's documented as "adenomatous", "polyposis", etc. and/or the ICD-10 book directs you to it. Example polyp of cecum codes to D12.0, per ICD-10 book. Now I do know that prior to 2020, the 2019 ICD-10 book would automatically direct you to code benign tumor when a site was documented for the polyp, however as of 2020 and on, the book no longer follows that criteria.
 
I agree, you cannot use D12 without the pathology confirmation. You can't assume that a polyp is a tumor or a neoplasm without physician documentation confirming this. If you assign D12 and the pathology comes back with something other than this, you'd need to resubmit a correction to your claim to remove that code. Perhaps you could ask your colleague to show you where in the LCD they are reading something that leads them to believe that they can do this?
 
My two cents on this is ~ why would you code anything at all? Why would you simply not wait? Both the patient (pathology report) and also the surgeon (operative report) should both wait for the pathology report? It is only a couple of days. Why, simply speculate on something and just guess to establish what really happened.
OH goodness I am completely acclimated on deadlines here from coding pathology, anesthesia, and otherwise.
Let us please be cognizant on continuing patient care. If you really need to bill that colonoscopy procedure to get your RVU's hasty without reviewing the pathology report. Well, probably shame on you that the "sigmoid colon polyp" that the surgeon extracted from the sigmoid colon was diagnosed as malignant. CAN YOU STATE MUD ON YOUR FACE! No, I will tell you all day long and all day strong that you should wait for the pathology report. I clearly understand the revenue cycle, but I also understand the continuity of patient care.
Let me provide an example. Patient referred for a colonoscopy (8/30) for whatever reason that was performed (9/10). The GI doctor stated in operative report that they had with forceps grasped a polyp and submitted it to pathology department for review. But because of all the billing haste from that facility they billed K63.5.
So therefore, the pathology coder throws K63.5 polyp of colon on the surgical procedure performed. But the next day the pathology report is issued by the pathologist's final interpretation that states it contains malignancy.
Well in my opinion - wait for the pathology report. I'm unsure if I need to get into the continuity of care here in my scenario, but it is seriously broken in my opinion.
Thank you for listening,
Dana
 
I agree with all of the above responses. If the path report hasn't been finalized yet then I would use K63.5. As others have said, it is best to wait for the path report to come back as this gives you the most detailed diagnosis. However, I understand your hands may be tied and coding before the path report is finalized is just how your department does it. In the end, regardless of what your coworkers say, you are ultimately the final say when it comes to how to code your account. Your coworker's name isn't on that account; yours is. I'm not trying to be disrespectful but just because someone has been a coder for a long time doesn't mean they know everything. All of us can learn bad habits. Myself included! Now, if this is a big issue in your department then I would suggest going to your boss and showing them the information you've received and asking them how they want this handled. In the meantime, below is some information I found on my coding software, 3M Encoder, that talks about hyperplastic vs adenomatous colon polyps. Hope this helps and good luck!

Hyperplastic versus adenomatous colon polyp

ICD-10-CM does not classify adenomatous (neoplastic) polyps of the colon the same as hyperplastic polyps. Code K63.5 describes a hyperplastic polyp and is the default when the type of polyp is not specified as adenomatous or neoplastic. Hyperplastic polyps, by definition, are not neoplastic, and are typically followed on a much different surveillance protocol than adenomatous polyps. Category D12, benign neoplasm of colon, rectum, anus and anal canal, classifies neoplastic polyps according to anatomic location.

Coding colonoscopies without pathology report

There is no requirement that coding cannot be done until all diagnostic results are available. Code to the highest degree of certainty what is known at the time of code assignment. Code K63.5, polyp of colon, is the default when the type of polyp is not specified as adenomatous or neoplastic regardless of the location in the colon.

References:
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 15 Effective with discharges: March 13, 2017
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Pages: 15-16 Effective with discharges: March 13, 2017
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Pages: 14-15 Effective with discharges: July 6, 2015
 
Per your pathology report if there is a K63.5 in one area and a d12 code in another area of the colon … those two codes hit against each other and cannot be coded together. I never final anything without having the pathology report in either.
 
nrwest said:
Per your pathology report if there is a K63.5 in one area and a d12 code in another area of the colon … those two codes hit against each other and cannot be coded together. I never final anything without having the pathology report in either.
Click to expand...
It's my understanding that if you have two separate polyps and one comes back as hyperplastic while the other is an adenoma then you can code both K63.5 and D12._. There is an exception to the Excludes 1 edit that states "an exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other." If it's clearly documented that there are two separate polyps then I believe both ICD-10 diagnosis codes can be coded especially if both were removed through different procedures (for example, 45380 and 45385).
 

MI_CODER,​

Do you seriously work your own pathology denials? I am not the betting type here, but will tell you now that if you throw a K63.5 with a D12. diagnosis for a claim it will be a BIG denial. BCBS (Blue Cross Blue Shield) is my favorite denial but I am seeing it clearly across the board with denials (not just commercial but government). I will share that BCBS throws the "principal diagnosis is missing" and once you review the claim and your ICD book that you clearly know that our "Excludes 1" trumps stuff that ultimately requires a correction.
I clearly have no idea on how much it costs to correct a claim for reimbursement from a coding or even billing perspective but let me share what I know.
You paid a pathology coder $xx.xx an hour to review this case, unfortunately which was denied ~ so I come in my casual role and correct the invoice. The healthcare facility paid the coder, and the biller to place this in a denial work queue, paid me to review it, that I corrected the invoice, so another biller needs to review and finally resubmit the invoice as a correction claim with proper adjudication rules that costs more money.
Or if you think that D12.* with K63.5 billed for either pathology specimen or pathology episode is adequate. You appeal those cases all day long in my opinion.
I will clarify on coding pathology specimen versus episode.
Specimen billing is that you receive 5 specimens and you bill the actual findings for each specimen.
When you bill for the episode; you bill the findings for the complete accession for all the specimens involved. What was the "intent"? That drives the yes, we bill for the episode or are we really billing each specimen?
I am hopeful I have helped,
Have a great evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHT
 
I do work my own denials when they're sent back to me. However, I've never had to work a denial when I code these two diagnoses together. I don't doubt that the insurance companies are being difficult when it comes to this rule. However, as I've stated before, there's an exception to the Excludes 1 rule. This exception specifically states that the two conditions can be coded if they're unrelated to each other. A hyperplastic polyp and an adenomatous polyp are two completely different types of polyps. Depending on the type of polyp determines how the provider is going to treat the patient. According to the AHA Coding Clinic, hyperplastic polyps are not neoplastic and are followed on a much different surveillance protocol than adenomatous polyps. With all that being said, if your provider is clearly documenting that a hyperplastic polyp was removed from one area in the colon and a adenomatous polyp was removed a different area in the colon then I truly believe that this would fit the exception to the Excludes 1 rule. You have two completely different types of polyps being removed from two completely different areas. These polyps, by definition and location, would be considered unrelated to each other. Whether or not the insurance wants to deny it is up to them but I believe this is the correct way to code it and we should be fighting the denial.

For example, let's say my provider documented that a screening colonoscopy was performed. He found a polyp in the sigmoid and a polyp in the cecum. The polyp in the sigmoid was removed via cold biopsy and the polyp in the cecum was removed via snare. The path report comes back as the polyp in the sigmoid was hyperplastic and the polyp in the cecum was adenomatous. I would codes this as follows:

45385-PT - Z12.11, D12.0
45380-59-PT - Z12.11, K63.5

What if both polyps were removed via snare? I would code it as follows:

45385-PT - Z12.11, D12.0, K63.5
 
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I am going to throw in another scenario here that I want to know - do you add the history of polyps if they removal a CURRENT polyp? My thought is no as the pt has active disease process so why add the Z code. However, a coder was instructed to do so - the Z12.11, D12.0, Z86.010. That does not make sense to me.

BTW - I have been BURNED, I submitted a lap appy with appendicitis once and GUESS WHAT? It was cancer!!! I was pressured by my supervisor submit all easy charges it's the end of the month.....I WILL NEVER DO THAT AGAIN!! It was early in my coding career. I now have 20 yr under my belt - I tell them no path, no posting.
 
Hi MI_CODER,
I so do apologize from your current post. You are coding surgical procedures and I am "out in left field simply coding pathology".
Goodness: please continue to do what you are doing, and I will be over here on another side of the fence dealing with pathology charges okay. I don't do surgical denials, so I clearly have no idea if that is relevant today.
Again, thank you for listening and responding.
Have a fantastic evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 

Hi, dimplez​

Who is billing this? I have seen so many crazy CCI edits lately I'm game to review what you have, and I state that sometimes you need to have another diagnosis code before what you assigned. It is all based on CCI edits. There are providers out there that expect that screening code, previous polyp or neoplastic process of colon first.
I will share that I reviewed a CCI edit our facility received from "Cigna" ~ four edits that didn't even qualify for the specimen at hand for a simple skin biopsy.
Off the top of my head, three were due to 88305 for (reproductive, screening related to colonoscopy, and something completely related to Barrett's esophagus" that this case doesn't qualify for ~ it was skin (remember). The diagnosis code D22.x didn't qualify for the colonoscopy. (Hmm, wonder why?)
 
danachock said:
Hi MI_CODER,
I so do apologize from your current post. You are coding surgical procedures and I am "out in left field simply coding pathology".
Goodness: please continue to do what you are doing, and I will be over here on another side of the fence dealing with pathology charges okay. I don't do surgical denials, so I clearly have no idea if that is relevant today.
Again, thank you for listening and responding.
Have a fantastic evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
Click to expand...
No worries Danachock! It was a good discussion :) Have a wonderful weekend.
 
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