To select the correct ICD-9 diagnosis code for a colonic polyp, gastroenterology coders need to know whether the polyp is benign or malignant. Often, however, the pathology report (PR) will not use either term. Instead a pathological description will be used that points to the usual behavior of the polyp, and coders need to be able to translate those descriptions into benign and malignant.
The PR contains the definitive determination of a colonic polyp’s behavior. To get the true picture of a polyp” you have to wait for the pathology report to come back ” says Roberta Classen CPC CPC-H MCS-P financial manager Charleston (S.C.) Gastroenterology Specialists and a member of the AAPC national advisory board. “Gastroenterologists may imply what type of polyp it is in an operative report but they usually defer to the pathology report before making a recommendation.”
Neoplasm Table Requires Information
Colonic polyps are growths of tissue that protrude from the bowel wall into the lumen. Some are neoplastic (from neoplasm) which means abnormal growth has occurred and there is potential for malignancy. Some are non-neoplastic which means that the growth consists of normal tissue with little or no potential for malignancy.
Coders should consult the neoplasm table in the ICD-9 Alphabetic Index to Diseases (Volume 2) when selecting a diagnosis code for a polyp. All diagnosis codes for neoplastic polyps will come from this table. Some of the diagnosis codes for non-neoplastic polyps will also come from this table.
The neoplasms table requires the coder to have three pieces of information about the polyp to choose the correct code:
1. The part of the body. For malignant primary neoplastic polyps in the colon the specific site of the colon (traverse sigmoid ascending descending etc.) must be indicated. For all other behaviors the code descriptions make a general reference to the colon large intestine or digestive system.
2. The behavior of the polyp or its capacity to spread. Benign (noncancerous ) and malignant (cancerous) are two types of behavior. In addition a colonic polyp could be classified as uncertain (235.2) which means that it can’t be determined if the polyp is malignant and the behavior is unpredictable and needs further investigation. It could also be unspecified (239.0) which means that the exact nature of the polyp must be determined by lab tests.
3. Whether the malignancy is primary secondary or in situ. A primary malignant colonic polyp (153.0-154.0) is one where the colon is the original site of the cancer. A secondary malignant colonic polyp (197.5) is one where the cancer has metastasized from another site to the colon. An in situ malignant colonic polyp (230.3-230.4) is one where the cancer is confined to the colon.
It is sometimes difficult to determine the primary site of a cancer because it has already spread to neighboring tissue. Code 153.8 can be used for a “malignant neoplasm of contiguous or overlapping sites of colon whose point of origin cannot be determined ” the ICD-9 manual states.
Morphologies of Non-Neoplastic Polyps
PRs often use a phrase that describes the morphology or form of the polyp such as adenomatous or hyperplastic. Because most morphologies are associated with a specific behavior the coder only has to understand the relationship between a particular morphology and its usual behavior to determine benign or malignant.
Although non-neoplastic polyps do not usually turn cancerous they may cause gastrointestinal problems such as bleeding and obstruction. Morphological descriptions of non-neoplastic polyps found in gastroenterology are:
Hyperplastic These polyps are frequently found in the colon and are believed to have no cancerous potential. Although they are not neoplasms hyperplastic polyps in the colon are usually reported with 211.3.
Mucosal These are usually benign and should also be reported with 211.3 when found in the colon.
Inflammatory or pseudopolyps These are found in patients with inflammatory bowel disease or ulcerative colitis. Use 556.4 (Pseudopolyposis of colon) to report these polyps instead of a code from the neoplasm table.
Hamartomatous Also called Peutz-Jeghers polyps they should be reported with 759.6 (Other and unspecified congenital anomalies; other hamartoses not elsewhere classified) rather than a code from the neoplasms table.
Morphologies of Neoplastic Polyps
The following morphological terms are often used in PRs to describe neoplastic polyps in the colon:
Adenomatous polyps (APs) Gastroenterologists believe that most colorectal cancers arise from this type of polyp but not all adenomas develop into cancer. Because of the potential for malignancy most insurers will reimburse follow-up and surveillance procedures for patients who have adenomatous polyps. Patients with APs are usually designated as having a history of colonic polyps (V12.72) according to Rosario Ligresti MD director of endoscopic ultrasound at New York Medical College in Valhalla.
When the pathological finding is referred to as an AP of the colon the behavior is benign and the diagnosis code will be 211.3. Instead of calling it an adenoma the PR may also use one of the three subcategories of adenomatous polyps to describe it. A tubular adenoma is a benign polyp. A villous adenoma of the colon is a carpet-like polyp that is usually uncertain (235.2). A tubulovillous adenoma is a combination of the tubular adenoma and villous adenoma and is usually benign.
Occasionally a polyp will be a combination of hyperplastic and adenomatous. Sometimes referred to as a serrated adenoma this mixed polyp should be treated as if it were adenomatous. It’s also common for patients to have multiple polyps of different morphologies such as pseudopolyps and APs. If the polyps have different diagnoses one for each type of polyp should be reported.
Adenocarcinomas When an adenomatous polyp becomes cancerous it is called an adenocarcinoma and is malignant. Two histological subcategories of adenocarcinoma in gastroenterology are tubular adenocarcinoma and villous adenocarcinoma which are also malignant.
Familial polyposis Also known as adenomatous polyposis coli this is a genetic condition where the patient has over a hundred adenomatous polyps in the colon. Familial polyposis is benign. It is almost certain however that colon cancer will develop from this condition and when it has turned malignant it is generally referred to as adenocarcinoma in adenomatous polyposis coli.
Gastrinomas These are relatively rare neuroendocrine tumors and are generally referred to as a gastrinoma (benign) and a malignant gastrinoma.
The following polyps are neoplasms often found in the colon that rarely become malignant and should be reported with 211.3: lipomas osteomas and leiomyomas.
If the polyp is malignant the PR will also provide information on whether it is primary secondary or in situ. “The gastroenterologist won’t be able to tell you if it’s primary secondary or in situ ” says Sherry Straub manager of coding at Esse Health a multispecialty practice in St. Louis. “You have to look to the pathology report.”
If the pathological description is simply “adenocarcinoma ” the malignancy is primary. “Adenocarcinoma metastatic” indicates that the cancer has metastasized and that this is a secondary site. If the malignancy is in situ that phrase should be part of the pathological description.
Some PRs use “metastatic from” and “metastatic to.” If the carcinoma is described as “metastatic from” a site it is considered to be the primary site. If the description is “metastatic to” a site it is considered a secondary site. In the description “metastatic carcinoma of the colon to the lungs” for example the colon should be coded as the primary site and the lungs would be the secondary site.
Once the diagnosis code has been found in the neoplasm table verify it in the Tabular List (Volume 1) of the ICD-9 manual. Straub says “Sometimes you’ll go there and find that code is really not what you wanted.”
The code descriptions in the tabular list help identify which sites of the colon are covered by a code. A benign polyp in the rectosigmoid junction for example should be reported not as a benign polyp of the colon but as a benign polyp of the rectum (211.4) even though the rectosigmoid junction is often lumped together with the colon in other ICD-9 descriptions.
Benign If No Pathology Report
When it is necessary to file the medical claim before the PR arrives colonic polyps should be reported as 211.3. “A polyp is considered benign until the PR indicates otherwise ” Classen explains. “You don’t want to incorrectly label a patient with cancer. The patient’s future insurance coverage could be jeopardized by an incorrect cancer diagnosis.”
Coders should also not rely on the gastroenterologist’s description of the polyp in the operative report when selecting the diagnosis code. “No mention of ‘benign’ or ‘malignant’ should be in the endoscopic report since at the time of the endoscopy we are never 100 percent sure without the pathologist ” Ligresti says. “If a gastroenterologist sees a large fungating ulcerated mass in the colon he shouldn’t say it’s colon cancer because it doesn’t always have to be. Ischemic colitis can often mimic colon cancer.”
The Funny Side of Life
Image by Boogies with Fish
www.messersmith.name/wordpress/2011/02/27/the-funny-side-…
As it was never difficult for me to find humour in the oddest corners of life, it has been disturbing recently that I don’t laugh as much as I used to. The reasons for this are multiple and obvious. Depression never gives one a cheerful outlook. Stress is not likely to invoke laughter. Trauma seldom makes one giggle. Nevertheless, I have discovered that I can regain areas of functionality by concentrating my attention on how I perceive life unfolding around me and consciously adjusting my habitual reactions to those perceptions. In other words, I give myself an attitude check.
For instance: It has now been nearly two weeks since I last posted. I’ve been fretting about this for days. Sometimes I simply can’t kick-start myself into action. Oh, I have a list of excuses as long as my ape-like arms. However, analysing it as objectively as I can, I have to admit that I just ran out of things to talk about. I needed to give myself some time to let the word well refill. Among other excuses were power outages. Several times as I sat with my hands poised over the keyboard composing the first sentence, the UPS screamed in agony and the air conditioner groaned and fell silent. Also there were rainstorms which blocked my satellite and killed my web connection. A few times I just felt "too tired" or I "had a headache" or I suddenly "got hungry" or any of several other manufactured distractions pulled me away from what I needed to get done.
So, what’s so funny about that? Well, nothing and everything. It’s not funny that a grown (dare I say mature?) man can find so many excuses to avoid doing something which he knows will make him feel better when he’s done it. It’s not funny that depression cripples us in so many unfathomable ways. The list of reasons why it’s not funny is lengthy. However, if you wrote a scene for a comedy and put Steve Martin in as the slightly disturbed and angst filled star, it would be very amusing. It might invoke some self-conscious giggles. Let’s have Steve preparing his CV for an important job application. I can see how he might never get around to actually doing it. Each time he starts and fails to complete the task it adds to the comedic frustration. As time goes by the distractions become more and more contrived. Forgot to feed the cat. Was that the telephone ringing? Oh, I need to trim my fingernails!
If I step outside my skin and watch myself, I have to admit that I resemble Steve in the movie. This strikes me as funny. It’s funny because it’s unreasonable. There’s an almost slapstick quality to it. Each little act of masochism is like a pratfall. One asks why is this guy doing this to himself? Why doesn’t he just get on with it?
Now that I’m writing, I feel better already, though when I read through what I’ve written I can’t imagine that anyone will make sense of it. Oh well, I am not here to make sense. That’s never been a goal.
I think that I’ve flogged that dead horse long enough. I’ll now show you some images from last week’s dive on the wall at Blueblood. I’ll try to find the humour in one of the worst dives I’ve had for ages. I’ll try to smile at a cold, rainy day.
We saw clear water as we approached the wall and prepared to go in. However, by the time we went over the side, we had drifted a bit and we ended up in a torrent of muddy water spilling out from the lagoon. The sky was very dark with grey rain clouds so there was little light. The water was so turbid that by the time we reached fifteen metres the visibility had dropped to less than two metres. I sincerely did not want to be there. I started to give Rich Jones the "I don’t like this" hand signal and pointed upward with my thumb. Rich just kept moving forward. I wasn’t happy about that, but the last thing that I wanted was for us to lose sight of each other. After a while we came into clearer water and things brightened up a bit. I got this shot of a nudibranch:
You may note that it is a bit grainy. That is because the light level was so low. I had to boost the ISO of my sensor to 400 to get an acceptable shutter speed. That is the point at which the Canon G11 gets noisy.
There were no big fish about, something which is becoming more and more common; I don’t know why. Everyone is commenting on it. We see no sharks these days and fish bigger than a hand are becoming less and less plentiful. I did, however, get a few nice shots of unusual corals. Here’s one:
My thumb is there to show you the size of the coral.
I like this shot of coral polyps streaming in the current:
This is a very young Leather Coral colony, I think:
And this is the most strangely coloured Fungia coral that I have ever seen:
It seems to me that these very strange colourations of many species of coral are becoming more and more common. I have no idea what causes it. It may be another manifestation of abnormalities caused by an increase of water temperature. This is something we have been experiencing for many years. The average temperature of the local reefs has risen considerably over the time which I have been diving here. We are seeing a huge increase of coral bleaching episodes.
I haven’t found much humour yet, so I’ll finish up with this grinning Moray:
Rich Jones found it hiding in a crevice. It was very difficult to get a shot. I took about ten exposures. This one was the best.
Choose Diagnosis for Colonic Polyps Based on Key Terms
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