Scenario: During a screening colonoscopy, a rectal polyp was found and removed via hot snare. The pathological findings revealed “hyperplastic polyp with focal adenomatous changes.” What code is assigned for the polyp? Should code K62.1, Rectal polyp, or code D12.8, Benign neoplasm of rectum, be assigned for a hyperplastic rectal polyp with focal adenomatous changes?
- Z12.11 Encounter for screening for malignant neoplasm of colon
- D12.8 Benign neoplasm of rectum
A mixed polyp would be treated clinically as an adenoma, which requires stricter surveillance and follow-up. Adenomatous polyps (adenomas) of the colon and rectum are benign (noncancerous) growths, but may be precursor lesions to colorectal cancer. Polyps greater than one centimeter in diameter are associated with a greater risk of cancer. If polyps are not removed, they continue to grow and can become cancerous.
The Alphabetic Index provides the following guidance for code selection:
- Rectum (nonadenomatous) K62.1
- Adenomatous – see Polyp, adenomatous
- Adenomatous – see also Neoplasm, benign, by site
First Quarter 2018 Coding Clinic, p. 6.