ICD-10-CM Coding of Colorectal Polyps

Types of Polyps

Adenomatous

Adenomas or adenomatous polyps are neoplastic in nature. These are precancerous polyps that have a high likelihood of becoming cancerous if left untreated. Patients diagnosed with adenomatous polyps are recommended to have more frequent cancer screenings. The frequency varies depending on the patient’s personal risk factors.

Types of adenomas:

• Tubular
• Villous
• Tubulovillous
• Sessile serrated
• Traditional serrated

Hyperplastic

ICD-10-CM Coding – Current Disease

ICD-10-CM classifies polyps of the gastrointestinal tract from the colon to the anus by whether the type of polyp is adenomatous, hyperplastic or unspecified and/or by site.

• Adenomatous polyps are reported from category D12 Benign neoplasm of colon, rectum, anus and anal canal and then further classified based on site
• Hyperplastic polyps are reported by site; K62.0 Anal polyp, K62.1 Rectal polyp, K63.5 Polyp of colon. The codes for hyperplastic polyps are the default when the type of polyp is not specified.
• A hyperplastic polyp with focal areas of adenomatous change is reported in the same way as an adenomatous polyp, with a code from category D12 Benign neoplasm of colon, rectum, anus and anal canal. This is based on the need for stricter surveillance and follow-up due to the presence of adenomatous tissue.

ICD-10-CM Coding - History of Polyps

ICD-10-CM has codes to report both personal and family history of colorectal polyps.

Personal History

• Since adenomas are neoplastic, a personal history of adenomatous polyps is reported with a code from subcategory Z86.01 Personal history of benign neoplasm with a 6th character of “0” for history of colonic polyp or a 6th character of “8” for history of adenomatous polyp of the rectum, anus or anal canal.
• Since hyperplastic polyps are not neoplastic it would be inappropriate to report a code from category Z86 Personal history of benign neoplasm for a history of hyperplastic polyp of the colon, rectum, anus or anal canal. A personal history of hyperplastic polyps of these sites is reported with code Z87.19 Personal history of other diseases of the digestive system.
• When the documentation states only “History of colon polyp(s)”, assign code Z86.010 because a diagnosis of History of colon polyp specifically indexes to code Z86.010.

Family History 

• A family history of any polyp reported with a code from category D12 Benign neoplasm of colon, rectum, anus and anal canal is assigned to code Z83.710 Family history of adenomatous and serrated polyps.
• A family history of hyperplastic colon polyp is reported with code Z83.711 Family history of hyperplastic colon polyps.
• A family history of hyperplastic polyps of the digestive system but not of the colon are reported with code Z83.79 Family history of other diseases of the digestive system.
• A family history of polyps of the colon that are not specified as either adenomatous or hyperplastic are reported with code. Z83.719 Family history of colon polyps, unspecified.

Coding With or Without the Path Report

There is no requirement that coding cannot be done until all diagnostic results are available. Every organization will need to develop their own policy regarding whether coding of procedures that include sending specimens for pathological analysis will be held until pathology reports are available for review and coders should check with the facility to determine what reports should be available prior to code assignment. Coders should code, to the highest degree of certainty, what is known at the time of code assignment whether that is before or after diagnostic results can be reviewed.

Examples

• A patient with personal history of tubulovillous adenoma of the colon presents for screening colonoscopy during which a hyperplastic polyp of the rectum is found and removed by snare technique.
  
  ICD-10-CM Diagnosis Codes: 
  K62.1 Rectal polyp
  Z86.010 Personal history of colonic polyps
  
  
• A patient with family history of colon polyps presents for screening colonoscopy during which a tubular adenoma of the descending colon and a polyp of the sigmoid colon are found and removed. 
  
  ICD-10-CM Diagnosis Codes:
  D12.4 Benign neoplasm of descending colon
  K63.5 Polyp of colon
  Z83.719 Family history of colon polyps, unspecified
  
  
• A patient presents for screening colonoscopy during which a polyp of the sigmoid colon was found and removed via hot snare. The pathological findings revealed hyperplastic polyp with focal adenomatous changes. 
  
  ICD-10-CM Diagnosis Codes:
  D12.5 Benign neoplasm of sigmoid colon

Take Aways

• Adenomatous polyps are reported as benign neoplasms
• Unspecified polyps are reported as hyperplastic
• Mixed polyps are reported as benign neoplasms
• A personal history of hyperplastic polyp is reported as a history of disease of the digestive disease.
• Personal history of all other polyps is coded as a personal history of benign neoplasm.
• Assignment of codes for family history of colorectal polyps is determined by type of polyp (adenomatous vs. hyperplastic) and site
• Coding is always based on the highest degree of certainty at the time of coding whether or not the path report is available for review.

References:

• AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2018: Page 6
  
• AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, First Quarter 2017, Pages: 14-17
  
• AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, Second Quarter 2015, Pages: 14-15
  
• wikipedia.org/wiki/Colorectal_polyp#Neoplastic_polyp
• Colon Polyps: Symptoms, Causes, Types & Removal (clevelandclinic.org)

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.