Coding Screening for Colorectal Polyp.
Colorectal cancer typically develops from a polyp. Polyps are abnormal growths of tissue (neoplasms) that can be found in any organ that has blood vessels ? and the colorectal area has a rich supply of blood vessels. Most polyps are benign, but they can become cancerous. Colon polyps found in the early stages usually can be removed safely and completely.
Symptoms may include bleeding from the anus, constipation or diarrhea that lasts more than a week, and hematochezia (blood in the stool) that can make stool look black or show up as red streaks in the stool. Most colon polyps are asymptomatic and people are unaware of them until one or more is found during a screening or other testing.
When selecting an ICD-10 diagnosis code for colon polyps, the precise location of the polyp(s) is key. The type of polyp (e.g., benign, inflammatory, etc.), as confirmed by biopsy, is also required.
Codes for benign adenomatous polyp of the colon are found in the neoplasm chapter of ICD-10-CM, by location:
- 0Benign neoplasm of cecum
- 1Benign neoplasm of appendix
- 2Benign neoplasm of ascending colon
- 3Benign neoplasm of transverse colon
- 4Benign neoplasm of descending colon
- 5Benign neoplasm of sigmoid colon
- 6Benign neoplasm of colon, unspecified [Note: This code includes adenomatous polyp of colon and polyposis of colon]
- 7Benign neoplasm of rectosigmoid junction
- 8Benign neoplasm of the rectum
Codes for inflammatory colon polyps, found in category K51 Ulcerative colitis, also are considered possible complications:
- 40Inflammatory polyps of colon without complications
- 411Inflammatory polyps of colon with rectal bleeding
- 412Inflammatory polyps of colon with intestinal obstruction
- 413Inflammatory polyps of colon with fistula
- 414Inflammatory polyps of colon with abscess
- 418Inflammatory polyps of colon with other complication
ICD-10 instructs to use an additional code with category K51 to identify manifestations (e.g., pyoderma gangrenosum).
Polyps of the colon not documented as adenomatous, benign, or inflammatory are coded to K63.5 Polyp of colon. If a colon polyp is specified as hyperplastic, assign K63.5, even if greater specificity is provided regarding the location, according to the American Hospital Association?s (AHA) Coding Clinic for ICD-10-CM and ICD-10-PCS (Second Quarter 2015, pages 14-15).