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K63.5
ICD-10-CM
Hyperplastic Polyp

Understanding Hyperplastic Polyp diagnosis, treatment, and clinical documentation is crucial for accurate medical coding. This resource provides information on Hyperplastic Polyp ICD-10 code, SNOMED CT code, histology, pathology, differential diagnosis, colonoscopy findings, and endoscopic mucosal resection considerations. Learn about sessile hyperplastic polyp, pedunculated hyperplastic polyp, and the significance of size, location, and number of polyps for appropriate management and coding guidelines.

Also known as

Non-neoplastic polyp
Benign colon polyp

Diagnosis Snapshot

Key Facts
  • Definition : Non-cancerous growths in the colon or rectum lining, usually asymptomatic.
  • Clinical Signs : Often found during colonoscopy, typically no noticeable symptoms unless large.
  • Common Settings : Gastroenterology clinics, endoscopy suites, colonoscopy screening.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC K63.5 Coding
K00-K95

Diseases of the digestive system

Includes conditions affecting the mouth, esophagus, stomach, intestines, and related organs.

D10-D36

Benign neoplasms

Covers non-cancerous growths in various body locations, including polyps.

K60-K62

Anus and rectum diseases

Includes various anorectal conditions, sometimes involving polyps.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the hyperplastic polyp of the colon?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Hyperplastic polyp
Sessile serrated adenoma
Traditional serrated adenoma

Documentation Best Practices

Documentation Checklist
  • Hyperplastic polyp size (mm)
  • Hyperplastic polyp location (specific)
  • Number of hyperplastic polyps found
  • Histological confirmation (if available)
  • Associated symptoms (if any)

Coding and Audit Risks

Common Risks
  • Unspecified Location

    Coding hyperplastic polyp without specifying anatomical location (e.g., colon, stomach) leads to claim rejection and inaccurate data.

  • Size Miscoding

    Incorrect documentation or coding of polyp size impacts clinical decision-making and potential for higher reimbursement.

  • Number Documentation

    Failing to accurately document the number of hyperplastic polyps identified can affect surveillance recommendations and coding accuracy.

Mitigation Tips

Best Practices
  • Code accurately: ICD-10 K31.A, SNOMED CT 81042001
  • Document size, location, morphology for CDI
  • Complete endoscopic report: polyp characteristics, removal method
  • Adhere to colonoscopy surveillance guidelines for compliance
  • Ensure pathology report correlates with endoscopic findings

Clinical Decision Support

Checklist
  • Confirm polyp size <10mm documented
  • Verify location in colon or rectum
  • Check pathology report for 'hyperplastic'
  • Exclude serrated features in documentation
  • Assess patient risk factors for CRC

Reimbursement and Quality Metrics

Impact Summary
  • Hyperplastic Polyp: Coding accuracy impacts reimbursement for colonoscopy procedures.
  • Accurate ICD-10-CM (K63.5) and CPT (45380/45385) coding maximizes revenue.
  • Proper documentation of polyp size, location, and number is crucial for optimal reimbursement.
  • Quality metrics for polyp detection rate and surveillance intervals are affected by coding and documentation.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective endoscopic resection techniques for diminutive and small hyperplastic polyps in the colon, considering factors like size, location, and morphology?

A: Diminutive and small hyperplastic polyps, particularly those less than 5mm and located in the rectosigmoid, are often managed with cold forceps polypectomy due to their low risk of malignancy. For slightly larger hyperplastic polyps or those with sessile morphology, hot snare polypectomy may be preferred to ensure complete removal and reduce the risk of recurrence. However, for polyps located in difficult areas like the proximal colon or those with a flat morphology, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) may be considered, although this is less common for purely hyperplastic lesions. The choice of technique should be guided by the endoscopic appearance, location, and size of the polyp, balancing the need for complete resection with the desire to minimize procedural risk. Explore how advanced endoscopic imaging modalities like narrow-band imaging (NBI) can aid in characterizing these polyps and guide resection decisions.

Q: How does the management of hyperplastic polyps differ in patients with serrated polyposis syndrome (SPS) compared to sporadic hyperplastic polyps, and what surveillance guidelines should be followed?

A: Managing hyperplastic polyps in patients with suspected or confirmed serrated polyposis syndrome (SPS) requires a different approach than managing sporadic hyperplastic polyps. While isolated, small hyperplastic polyps are typically considered low risk, the presence of multiple serrated lesions, especially those with features like large size (>1cm), proximal location, or a mixed morphology, raises the risk of synchronous or metachronous colorectal cancer. Patients with SPS require more intensive surveillance colonoscopy, often at shorter intervals (e.g., 1-3 years) depending on the number and characteristics of the serrated lesions. Complete removal of all identifiable serrated polyps is crucial. Consider implementing a standardized endoscopic reporting system to accurately document polyp characteristics and guide surveillance strategies. Learn more about the specific criteria for diagnosing SPS and the recommended surveillance guidelines from reputable gastroenterological societies.

Quick Tips

Practical Coding Tips
  • Code K31.1 for hyperplastic polyp
  • Document location, size, number
  • Distinguish from adenomatous polyp
  • Consider colonoscopy findings
  • Confirm with pathology report

Documentation Templates

Patient presents with complaints suggestive of a hyperplastic polyp.  Symptoms may include rectal bleeding, changes in bowel habits, or incidental finding during colonoscopy screening for colorectal cancer.  Physical examination including digital rectal exam may reveal no significant abnormalities.  Colonoscopy revealed a sessile hyperplastic polyp measuring less than 5mm located in the rectumsigmoid colon.  The polyp appeared pale, smooth, and without pedunculation.  Biopsy confirmed the diagnosis of hyperplastic polyp, demonstrating characteristic microscopic features of serrated architecture without cytologic dysplasia.  Differential diagnoses included adenomatous polyp, sessile serrated adenoma, and traditional serrated adenoma.  Given the small size and benign histology, endoscopic resection was performed during the colonoscopy, and complete removal was confirmed.  The patient tolerated the procedure well.  Diagnosis of hyperplastic polyp rectum, ICD-10 code K62.1, was assigned.  The patient was advised on the importance of routine colon cancer screening and surveillance colonoscopy based on current guidelines.  No further treatment is indicated at this time.  Follow-up colonoscopy is recommended.  Patient education provided regarding polyp formation, colon cancer risk factors, and dietary recommendations for colon health.  Emphasis placed on increasing fiber intake and maintaining a healthy lifestyle.