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diagnosis reporting on polypectomy

Bill Posted Fri 25th of April, 2014 14:16:34 PM

Can you tell me if you should wait for the final pathology report before coding a polypectomy? I always hold charges until I get the final path report to see if polyp is benign or malignant. Can you advise on this?

SuperCoder Answered Fri 25th of April, 2014 17:01:12 PM

Whether or not you're dealing with a full-blown colorectal cancer, you should be looking at the different terms used to describe benign or malignant colonic polyps. Some of these include:

Adenomas including tubular adenomas and tubulovillous adenomas
Hyperplastic polyps
Inflammatory polyps
Familial adenomatous polyposis, a rare hereditary disorder that causes hundreds of polyps in the lining of the colon beginning in the teenage years. If this is left untreated, the patient becomes high risk to develop colon cancer.
Hereditary nonpolyposis colorectal cancer, a hereditary disorder that causes an increased risk of developing colon cancer.
But first, you have to accomplish the task of determining -- without a doubt -- if a polyp is benign or malignant. If you think you would find the clues in the pathology report (PR), think again. Usually, the PR will not use the term "benign" or "malignant." However, it will use a description that points to the usual behavior of the polyp. It's up to you to interpret those descriptions into benign or malignant.

Important: Experts advise that you always wait for the pathology report to come back before deciding on a particular ICD-9. Even the gastroenterologists, themselves, usually defer to the pathology report before making a recommendation.

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