tci General Surgery Coding Alert - 2021 Issue Q3

Reader Questions: Dictate Dx from Pathology Report

Question: We’re coding an op report for an excised polyp from the rectosigmoid junction that the surgeon identifies as a “colon polyp,” but the pathology report identifies as “hyperplastic polyp.” What is the correct diagnosis code for this case? Florida Subscriber Answer: You should base the diagnosis code on the pathologist’s final diagnosis, not the surgeon’s designation, if they differ. The correct code for a hyperplastic polyp of the rectosigmoid junction is D12.7 (Benign neoplasm of rectosigmoid junction). For hyperplastic polyps, the correct subcategory is D12.x with the fourth character...

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