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Pathology/Lab Coding Alert

Case Study:

Find Polyp Dx in Screening Colonoscopy

Focus procedure code, too.

Specimens from colonoscopy procedures are common fare for pathologists, but coding the cases could lead to some uncommon choices.

Look at the following case for some quick insights into diagnosis and procedure codes for colon-specimen cases.

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The surgeon submits a “biopsy of the descending colon” from a screening colonoscopy procedure.

The pathologist examines the specimen and describes a 1.8 cm polyp with abnormal cells consistent with low grade dysplasia. The report identifies a predominately tubular growth pattern with 15 percent villous growth pattern and concludes that the diagnosis is tubular adenoma.

Do this: Code the pathologist’s work as 88305 (Level IV - Surgical pathology, gross and microscopic examination; … polyp, colorectal …).

Although the surgical report identified the specimen as a colon biopsy and the pathology report identified the specimen as a colon polyp, it is a distinction without a difference as far as CPT® is concerned. “The correct code for pathology exam of a colon biopsy is the same as colon polyp: 88305 (… colon, biopsy …), says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Maneuver Through Dx Code Minefield

You have two pieces of information regarding the diagnosis for this case. First, the surgeon submits the specimen without signs and symptoms because the case is a screening colonoscopy, and second, the pathologist’s diagnosis is tubular adenoma.

Findings: When coding the case, you should report any findings as the diagnosis. “Remember that you should always complete diagnosis coding after the pathology report is available,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, national director of marketing and revenue management at FasPsych in Omaha, Nebr.

Dx pitfall: The pathologist’s diagnosis for the colonic polyp of the descending colon is tubular adenoma. But if you reported K63.5 (Polyp of colon) for the diagnosis code, you would be wrong. Reading the Excludes1 note under K63.5, you can see that the code does not describe an adenomatous polyp. Tubular adenoma is an adenomatous polyp, so you should report the diagnosis as D12.4 (Benign neoplasm of descending colon).

That’s as far as the pathologist needs to go when assigning the ICD-10-CM code. In fact, the pathologist may choose to simply report the narrative diagnosis in the pathology report to the surgeon, in which case the surgeon assigns the D12.4 code.

Extended view: Because this is a screening colonoscopy, the surgeon will need to list first the screening code, Z12.11 (Encounter for screening for malignant neoplasm of colon), and then list the final diagnosis D12.4. Depending on the payer, the surgeon may also need to append a modifier such as PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) or 33 (Preventive services) to the procedure code, because the screening colonoscopy converted to a diagnostic colonoscopy upon taking a biopsy.