What should I use for the diagnosis for this?
Screening colonoscopy:
A rectal examination was performed. The Olympus pediatric colonoscope was inserted into the rectum and advanced under direct vision to the cecum, which was identified by the ileocecal valve and appendiceal orifice. The quality of the colonic preparation was good. A careful inspection was made as the colonoscope was withdrawn, including a retroflexed view of the rectum; findings and interventions are described below.
Screening colonoscopy:
A rectal examination was performed. The Olympus pediatric colonoscope was inserted into the rectum and advanced under direct vision to the cecum, which was identified by the ileocecal valve and appendiceal orifice. The quality of the colonic preparation was good. A careful inspection was made as the colonoscope was withdrawn, including a retroflexed view of the rectum; findings and interventions are described below.
FINDINGS: -hemorrhoids (internal and external), Moderate in size
-polyp(s) – #1, 5 mm in size, Flat, the transverse colon, removed by hot biopsy and sent for pathology
Path report: Transverse colon polypectomy-Colonic mucosa with no significant histopathologic abnormalities.
I would think this polyp would not be coded if it’s only benign colonic mucosa, but it was removed, so if I code only Z12.11, would 45384 be covered? Would the polyp be coded as benign neoplasm D12.3? When I look under polyp/colon/transverse, that’s what it leads to.