I'm having a conundrum of sorts with something that should be relatively easy. What would you code for "rectosigmoid polyp"? If I follow the index from polyp, rectum, I arrive at K62.1 – rectal polyp. If I follow the index from polyp, colon, sigmoid, I get D12.5 – Benign neoplasm of sigmoid colon. Just below this is D12.7 – Benign neoplasm of rectosigmoid junction, but I cannot figure out a way to get to this code through the index. So, which is it K62.1, D12.5, or D12.7?Thanks,Laura
I would advise looking at Coding Clinic, First Quarter, 2017, pages 15-16. If you do not have access to Coding Clinic, here is an excerpt.
There is no requirement that coding cannot be done until all diagnostic results are available. Code to the highest degree of certainty what is known at the time of code assignment. As previously stated, code K63.5, Polyp of colon, is the default when the type of polyp is not specified as adenomatous/neoplastic regardless of the location in the colon.
The Official Guidelines for Coding and Reporting for outpatient services state, "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation."
For coding purposes, facilities may develop specific policies regarding which reports must be available in order to complete code assignment."
I hope you find this helpful!
So, according to this coding clinic then, "rectosigmoid polyp" is simply assigned to K63.5, since I do not have any further description or specificity. I feel the index is a little misleading or confusing, since adenomatous is indexed on its own, without any further indexing of sites and that the other sites of the colon are listed on their own without any further indexing to what type of polyp they are. It would seem to make more sense to index the types and then further index the types by site. Even if "hyperplastic" and "andenomatous" were the only types indexed, coders would then be able to see that the type of polyp is necessary information to further code and if the type is not known, then the main index would be what should be turned to in the tabular. Thank you for pointing out the Coding Clinic.