Find information on documenting and coding a personal history of colon polyps for accurate clinical records. This resource covers ICD-10 code Z86.01, SNOMED CT, medical necessity guidelines, past medical history documentation best practices, and the importance of precise terminology for colon polyp history in healthcare settings. Learn about the significance of detailing polyp characteristics, including size, number, location, and histology, for comprehensive patient care and proper medical coding compliance.
Also known as
Personal history of colonic polyps
Personal history of benign neoplasm of colon.
Personal history of malignant neoplasm of colon
History of primary malignant neoplasm of colon.
Encounter for screening for colorectal cancer
Patient encounter for screening for colorectal cancer.
Follow this step-by-step guide to choose the correct ICD-10 code.
History of colon polyps confirmed?
Yes
Polyps removed?
No
Do NOT code Z86.010. Review documentation for alternative diagnosis.
When to use each related code
| Description |
|---|
| History of colon polyps |
| History of adenomatous polyp |
| Family history of colon polyps |
Coding Z87.0 requires specifying polyp type (e.g., adenomatous vs. hyperplastic) for accurate risk assessment and surveillance.
Missing polyp location details (e.g., colon segment) hinders proper coding, affecting quality metrics and reimbursement.
Absent documentation of the last colonoscopy date complicates coding and impacts surveillance guidelines compliance.
Q: What is the recommended colonoscopy surveillance interval after a patient presents with a personal history of small, hyperplastic colon polyps?
A: The recommended colonoscopy surveillance interval after a patient presents with small (<10mm), hyperplastic colon polyps located in the rectosigmoid colon and no other concerning findings is generally 10 years, aligning with current guidelines for average-risk individuals. However, factors such as the number of hyperplastic polyps, their location (proximal colon raises concern), family history of colorectal cancer, and presence of concomitant adenomas may influence the surveillance interval. Consider implementing a risk-stratified approach to personalize surveillance recommendations based on these factors. Explore how S10.AI can assist in risk stratification for colonoscopy surveillance.
Q: How should a clinician manage a patient with a personal history of multiple serrated colon polyps, considering the increased risk of future colorectal cancer?
A: Managing patients with a history of serrated polyps requires a more nuanced approach due to their distinct characteristics and associated risks. Serrated polyps, particularly sessile serrated adenomas (SSAs), carry a higher risk of synchronous and metachronous colorectal cancer compared to conventional adenomas. For patients with a history of multiple serrated polyps, particularly those larger than 1 cm or those with dysplasia, a shorter surveillance interval (e.g., 3-5 years) is often recommended. Additionally, complete removal of all detected serrated polyps is crucial. Explore how S10.AI can aid in accurate polyp characterization and inform surveillance strategies for patients with a personal history of serrated polyps.
Patient presents with a personal history of colon polyps. The patient reports previous colonoscopy findings of (number) polyp(s) identified in the (location, e.g., sigmoid colon, rectum) on (date). The polyp(s) were characterized as (type, e.g., tubular, villous, tubulovillous adenoma, hyperplastic) and measured (size in mm). Histopathology confirmed (diagnosis, e.g., benign, adenomatous with low-grade dysplasia, high-grade dysplasia). The patient underwent (procedure, e.g., polypectomy, endoscopic mucosal resection) at that time. Subsequent surveillance colonoscopies were performed on (dates), revealing (findings, e.g., no polyps, recurrent polyps, no evidence of disease). The patient denies any current symptoms of rectal bleeding, abdominal pain, change in bowel habits, or unexplained weight loss. Family history is significant for (family history of colon cancer or polyps - specify relationship and age of diagnosis). Assessment: Personal history of colon polyps. Plan: Discussed the importance of continued colon cancer screening and surveillance colonoscopy as per established guidelines, considering patient's history and risk factors. Patient education provided regarding dietary recommendations, including increased fiber intake, and lifestyle modifications to reduce colon cancer risk. Scheduled for follow-up colonoscopy in ( timeframe, e.g., 3 years, 5 years) or sooner if indicated. Colon polyp prevention, colonoscopy procedure, colon cancer screening, colorectal cancer, polyp removal, bowel health, gastrointestinal health, precancerous polyps, adenoma, polyp pathology, endoscopic resection, surveillance colonoscopy interval.