Wiki Office visit following colonoscopy/polypectomy

[abney.pam@mhsil.com]

Scenario: Provider sees a patient in the office for a follow up to discuss their polypectomy/colonoscopy results, benign polyps were removed and he makes recommendations for constipation. We have always used history of colon polyp Z86.010 on the office visit since it was removed and are now being told that it is considered "active" and to code the listed pathology report code, ie: D or K codes. I have researched this and can only find guidelines that imply use of history codes to be most appropriate for this scenario since the polyps no longer exist and would only use the D or K codes if the provider states that there was residual tissue that could not be removed.

Would appreciate guidance and reference on this.

 

[such78]

Report Z48.815-encounter for surgical aftercare following surgery on the digestive system as the first listed diagnosis, following with Z86.0100 - personal history of colon polyps unspecified as secondary diagnosis.

OCG: 21. Chapter 21:
7) Aftercare
The aftercare codes are generally first listed to explain the specific reason for the encounter. An aftercare code may be used as an additionalcode when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. An example of thiswould be the closure of a colostomy during an encounter for treatment of another condition.