Find comprehensive information on coding and documenting a history of polyps. This resource covers polyp diagnosis history, including ICD-10 codes for history of colon polyps, nasal polyps, gastric polyps, and other polyp types. Learn about proper clinical documentation for past polyp removal, polyp surveillance, and family history of polyps. Explore resources for healthcare professionals regarding the management and coding of a patient with a history of polyps.
Also known as
Intestinal polyps
History of polyp(s) of the intestine, except rectum and anus.
Polyp of rectum and anus
History of polyp(s) of the rectum and anus.
Benign neoplasm of colon
Includes history of benign colonic polyps.
Personal history of colonic polyps
Specifically documents past colonic polyps.
Follow this step-by-step guide to choose the correct ICD-10 code.
Where was the polyp located?
When to use each related code
| Description |
|---|
| History of colon polyps |
| History of nasal polyps |
| History of gastric polyps |
Coding lacks specificity (e.g., colon, stomach). Impacts quality metrics and reimbursement. CDI can clarify location.
Documentation lacks detail (e.g., adenomatous, hyperplastic). Affects risk stratification and surveillance coding.
Incorrectly coding current polyp as history or vice versa. Leads to inaccurate clinical data and potential overpayment/underpayment.
Patient presents with a history of colonic polyps. The patient reports previous colonoscopies revealing adenomatous polyps, the specific histology and size of which are detailed in prior records. The patient's family history is significant for colon cancer, increasing their risk for colorectal cancer. Current symptoms, if any, include (document specific symptoms such as rectal bleeding, changes in bowel habits, abdominal pain, or anemia). Physical examination findings are unremarkable, aside from (document any relevant findings). Assessment: History of colon polyps, with increased risk due to family history of colon cancer. Plan: Continued surveillance colonoscopy is recommended, with frequency determined by prior polyp size, histology, and number, in accordance with established guidelines (e.g., US Multi-Society Task Force on Colorectal Cancer). Patient education regarding polyp recurrence, colorectal cancer screening, and importance of adherence to the recommended surveillance schedule was provided. Dietary recommendations and lifestyle modifications for colorectal cancer prevention were also discussed. The risks and benefits of continued surveillance were explained, and the patient verbalized understanding. Follow-up scheduled for (date).