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Rectal Polyp

Hi

I was wondering if I could get help on a problem we are having with GI and CRNA charges not matching up there for they are not getting paid. I do the coding for GI Physician and hospital coding and the CRNA charges are being coded from an outside vendor. A problem we are running into is a patient came in for instance 3 years ago and had a rectal polyp removed, my Dr puts patient on a 3 year recall to come and get another colonoscopy done, he also puts indication for colon and on his H&P reason for patient coming in as History of polyps. I as the GI coder am putting the Z86.010 history of polyps for reason patient is coming in as well. The CRNA coder is putting Z12.11 as the reason because it was a rectal polyp found in the past and not a colon polyp. Does anyone have any input or resources on this, I have a meeting next week to verify what should be happening.

Thanks
Jenny

Medical Billing and Coding Forum

Surgeon states polyp pathologist states normal

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

Medical Billing and Coding Forum

Full Thickness Resection of Colonic Polyp

Hello,

Please advise on the coding of the following polyp removal with full thickness resection device. Is an unlisted appropriate in this scenario?

A 12 mm polyp was found in the recto-sigmoid colon at 15 cm from the anal verge. Polyp has associated scar from prior
treatment and adjacent SPOT tattoo. The polyp was sessile. Preparation for full thickeness resection was made. The
margin of the lesion was marked with the cautery marking device. The colonoscope was exchanged for a new colonoscope
with the attached Full Thickness Resection Device. The Device was driven to the lesion. The lesion was grasped with the
grasping forceps into the cap, care taken not to use suction. The closure device was then deployed and the lesion
ensnared in the indwelling snare. Full thickness resection was then performed. Edges trimmed with dual knife and snare.
After scope and specimen removal the site was again evaluated showing appropriate clip placement with no perforation,
bleeding or residual lesion seen.
External hemorrhoids were found during

Any help is greatly appreciated.

Thank you

Medical Billing and Coding Forum

Pathology Results Coding for an Ascending Polyp

Would you be able to help me with a path report dx? I’m not even sure where to start looking. :confused:

A polyp was removed from the ascending colon: Path reportresults:
· Inflammatory polyp with increasedlymphoplasmacytic cells and eosinophils within the lamina propria.
· Marked Edema without ulceration.
· No evidence of active or chronic cryptitis orgranulomatous inflammation
· No adenomatous change or malignancy.

Thank you!

Medical Billing and Coding Forum