A patient undergoes surveillance upper gastrointestinal (GI) endoscopy due to a personal and family history of familial adenomatous polyposis (FAP). The endoscope is introduced into the mouth and after thorough examination of the upper gastrointestinal tract, no evidence of a mass or polyp is found. What diagnosis codes are assigned for a personal and family history of FAP? Is this surveillance endoscopy considered a screening or a follow-up exam?
Assign code Z12.89, Encounter for screening for malignant neoplasm of other sites, for the surveillance upper GI endoscopy. Codes Z86.010, Personal history of colonic polyps, Z83.71, Family history of colonic polyps, Z15.09, Genetic susceptibility to other malignant neoplasm, and Z84.81, Family history of carrier of genetic disease, should also be assigned.
A surveillance endoscopy is still a screening for malignancy, and in this case, the endoscopy is considered a high-risk screening exam, because of the history of FAP.