Find comprehensive information on Colon Polyp diagnosis, including clinical documentation, medical coding (ICD-10, SNOMED CT), polyp types (hyperplastic, adenomatous, sessile, pedunculated), colonoscopy procedures, pathology reports, and treatment options. Learn about polyp size, location, histology, dysplasia, and surveillance guidelines for healthcare professionals. Explore resources for accurate and efficient medical record keeping related to colon polyps.
Also known as
Polyp of colon
This code specifies the presence of a polyp in the colon.
Benign neoplasm of colon
Includes benign growths in the colon, encompassing some polyps.
Diseases of intestine NOS
A broader category including various intestinal conditions, some related to polyps.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the polyp neoplastic?
Yes
Is it adenomatous?
No
Is it inflammatory?
When to use each related code
| Description |
|---|
| Colon Polyp |
| Diverticulosis of Colon |
| Angiodysplasia of Colon |
Coding colon polyp without specifying location (e.g., transverse, sigmoid) leads to inaccurate DRG assignment and reimbursement.
Incorrectly documenting or coding polyp size can impact surveillance guidelines and appropriate procedural coding (e.g., polypectomy vs. resection).
Failing to document and code polyp histology (e.g., adenomatous vs. hyperplastic) impacts risk stratification, treatment, and cancer registry data.
Q: What are the most effective surveillance strategies for colon polyps based on size, histology, and number detected during colonoscopy?
A: Surveillance strategies for colon polyps are individualized based on a combination of factors, including size, histology, number, and patient-specific risk factors like family history and age. For small hyperplastic polyps (<10mm), routine colonoscopy at standard intervals (e.g., 10 years) is usually sufficient. However, for adenomatous polyps, particularly those >10mm, high-grade dysplasia, or villous features, more frequent surveillance is indicated. For example, three or more adenomas, or an adenoma >1cm, might warrant a repeat colonoscopy in 3 years. The presence of sessile serrated polyps necessitates closer follow-up based on size and location, potentially as early as 1-3 years. Multiple or large serrated lesions may necessitate even shorter intervals. Explore how specific risk stratification tools and guidelines, like those from the US Multi-Society Task Force on Colorectal Cancer, can inform personalized surveillance strategies for your patients.
Q: How do I differentiate between hyperplastic and adenomatous colon polyps during colonoscopy, and what are the implications for management and follow-up?
A: Differentiating between hyperplastic and adenomatous polyps during colonoscopy can be challenging, relying on visual assessment, but ultimately confirmed with histopathological examination. Hyperplastic polyps, typically smaller and located in the distal colon and rectum, appear smooth and sessile. Adenomatous polyps, on the other hand, possess greater malignant potential and can exhibit variable morphology including pedunculated, sessile, or flat shapes. They may also appear more irregular in color and texture. Histological analysis confirms the diagnosis and guides management. While hyperplastic polyps are generally considered low risk, adenomatous polyps require removal and surveillance based on their features (size, dysplasia grade). Consider implementing enhanced visualization techniques (e.g., narrow-band imaging, chromoendoscopy) during colonoscopy to improve polyp detection and characterization. Prompt and accurate histological assessment is crucial for appropriate management and follow-up.
Patient presents with complaints suggestive of a colon polyp, including (but not limited to) rectal bleeding, changes in bowel habits (such as constipation or diarrhea), abdominal pain, andor anemia. Relevant medical history includes colonoscopy findings, family history of colon cancer or polyps, inflammatory bowel disease, and any prior polypectomies. Physical examination may reveal abdominal tenderness or palpable masses. Diagnostic evaluation including colonoscopy with biopsy confirms the presence of a colon polyp. The polyp's location (e.g., ascending colon, transverse colon, descending colon, sigmoid colon, rectum), size (in millimeters), morphology (e.g., sessile, pedunculated), and histopathology (e.g., tubular adenoma, villous adenoma, tubulovillous adenoma, hyperplastic polyp) are documented. Differential diagnoses considered include colorectal cancer, diverticulitis, hemorrhoids, and inflammatory bowel disease. Treatment plan includes endoscopic polypectomy (e.g., snare polypectomy, hot biopsy forceps), surveillance colonoscopy based on polyp characteristics and risk stratification guidelines, and patient education regarding colon cancer screening and prevention. Potential complications discussed include bleeding, perforation, and incomplete polyp removal. Follow-up care includes monitoring for recurrence and adherence to recommended surveillance intervals. ICD-10 code D12.x is used for coding purposes, with the specific fifth character indicating the location of the polyp. CPT codes for colonoscopy and polypectomy are determined by the complexity of the procedure.