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Diagnosis for nonspecific colonoscopy findings

Dawna Posted Tue 23rd of October, 2012 13:39:11 PM

What diagnosis code would you use based on the following:

Procedure:
Colonoscopy:
Multiple pedunculated polyps were found in the transverse colon and in the ascending colon consistent with inflammatory polyps. There was patchy erythema throughout colon, multiple random biopsies taken with cold forceps.

Pathology Results:
"Final Diagnosis:
A. RIGHT COLON, RANDOM ENDOSCOPIC BIOPSIES:
- FOCALLY POLYPOID FRAGMENTS OF COLONIC MUCOSA WITH NONSPECIFIC
CHANGES
B. LEFT COLON, RANDOM ENDOSCOPIC BIOPSIES:
- COLONIC MUCOSA WITHOUT DIAGNOSTIC ALTERATION"
Diagnosis comment on pathology report: "The specimens contain colonic mucosa with focal polypoid change in the right colon and areas of lymphoid aggregation in the right colon and rectosigmoid specimens. Mild lamina propria edema and chronic inflammation are identified, and the polypoid changes in the right colon specimen would be compatible with old inflammatory polyps. There is no evidence of malignancy or dysplasia and there is no histologic evidence of active inflammatory bowel disease."

The indication for the colonoscopy is "High risk colon cancer surveillance, ulcerative colitis".

What would the most appropriate dx be?

SuperCoder Answered Tue 23rd of October, 2012 20:07:30 PM

I would use 211.3 for FOCALLY POLYPOID FRAGMENTS OF COLONIC MUCOSA that much equal to colonic polyp and 569.89 for COLONIC MUCOSA WITHOUT DIAGNOSTIC ALTERATION.

Dawna Posted Wed 26th of December, 2012 15:35:40 PM

Since the colonoscopy started off as a screening, would you also use V76.51?

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