tci General Surgery Coding Alert - 2022 Issue Q1

Reader Questions: Highlight Preventive Colonoscopy

Question: We have a case in which the surgeon performed a screening colonoscopy, but found and removed a polyp in the transverse colon. The pathology report identified the polyp as a tubular adenoma. What is the correct diagnosis coding for the case? Ohio Subscriber Answer: Although the typical advice for a surgical case is to report just the pathology diagnosis, doing so is not appropriate in this situation. Because this is a screening colonoscopy that turned diagnostic when the surgeon removed a polyp, you need to capture that information with diagnosis codes. The diagnosis coding in this case has...

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