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

Hyperplastic polyps are very common and are encountered more often in the distal colon. Typically, hyperplastic polyps are slow-growing and not pre-cancerous. Hyperplastic polyps, by definition, are not neoplastic, and are typically followed on a different surveillance protocol than adenomatous polyps.

Inflammatory

ICD-10-CM Coding – Current Disease

ICD-10-CM classifies polyps of the colon or rectum by whether the type of polyp is adenomatous, hyperplastic, inflammatory or unspecified and/or by site or complication.

• 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; K62.1  Rectal polyp or K63.5  Polyp of colon. The codes for hyperplastic polyps are the default when the type of polyp is not specified.
• Inflammatory polyps of the colon are reported with codes from subcategory K51.4 Inflammatory polyps of colon and further specified as without complication or by type of complication such as rectal bleeding or abscess.
• 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

• A personal history of colon polyps is reported with a code from subcategory  Z86.01  Personal history of benign neoplasm with a 6th character of “0” for personal history of colon polyps and a 7th character identifying the type of polyp as adenomatous, serrated, hyperplastic, other (includes inflammatory) or unspecified. Based on the includes note under code Z86.010, a personal history of colorectal or rectal polyps is also included for reporting in this subcategory.

Family History 

• A family history of adenomatous and serrated colon polyps is reported with 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 colon polyps other than adenomatous, serrated, or hyperplastic (e.g., inflammatory) is reported with code  Z83.718  Other family history of colon polyps.
• A family history of polyps of the colon that are not specified as either adenomatous, serrated, hyperplastic or of other type are reported with code Z83.719  Family history of colon polyps, unspecified.
• A family history of familial adenomatous polyposis is reported with code Z73.72.

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
  • Z86.0101  Personal history of adenomatous and serrated colon 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
• Personal history of colon 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 (e.g., adenomatous vs. hyperplastic vs. other)
• 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:

• ICD-10-CM Alphabetic Index and Tabular List
• 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, 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.