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Surgeon states polyp pathologist states normal

  1. #1
    Default Surgeon states polyp pathologist states normal
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    Hi,

    I've a case where the encounter is for screening colonoscopy (ICD-10-CM: Z12.11). The surgeon found a polyp (ICD-10-CM: K63.5) in the transverse colon and excised it using snare (CPT 45385). Pathology report comes a few days later and states the excised tissue as "normal colonic mucosa".

    Did the surgeon excised normal tissue only and if that is the case what would be the codes? Should we code for biopsy only and not snare since there was no lesion that was excised and was rather normal tissue?

    I've narrowed it down to:

    1. ICD-10-CM: Z12.11, K63.5; CPT: 45385; OR
    2. ICD-10-CM: Z12.11; CPT: 45380

    Any insights?

    Thanks!

    Amber

  2. #2
    Smile Gastro Procedure
    Hi Amber

    The surgeon notation sounds correct and pathologist definition is the same thing...code with dx K63.5 and Z12.11 using CPT 45380. If he used a snare removal technique it should say in doc's notation then code properly. By the way you code by the attending physician ' s documentation. However if the pathologist and attending physician disagree, you code to what the attending doc has dictated or said. However you can inform the attending physician (or query) to see if he wants to amend the record per the dx. the pathologist has given.

    Just saying

    Have a great day!

    Lady T

  3. #3
    Default
    Quote Originally Posted by TThivierge View Post
    Hi Amber

    The surgeon notation sounds correct and pathologist definition is the same thing...code with dx K63.5 and Z12.11 using CPT 45380. If he used a snare removal technique it should say in doc's notation then code properly. By the way you code by the attending physician ' s documentation. However if the pathologist and attending physician disagree, you code to what the attending doc has dictated or said. However you can inform the attending physician (or query) to see if he wants to amend the record per the dx. the pathologist has given.

    Just saying

    Have a great day!

    Lady T
    Thank you for the response Lady T

    Actually, the pathology reports that I've received for such cases often mention the terms such as "Hyperplastic polyp" or "Adenoma". If the sugeon states polyp and pathologist states adenoma, I code adenoma (It's just like if surgeon excises a tumor and pathology report confirms if it's benign or malignant and it's then coded depending on the final diagnosis from the pathology report as benign or malignant).

    But, I don't understand what to do if surgeon states polyp and the pathologist states normal tissue (Shouldn't the final diagnosis be normal tissue?).

    Are you saying that even a polyp can appear like normal tissue to the pathologist? Please correct if I misunderstood your reponse.

    Thanks!

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