The patient presents with (symptoms such as rectal bleeding, change in bowel habits, abdominal pain, or incidental finding during screening colonoscopy).  Colonoscopic examination reveals a (sessile or pedunculated) polyp located in the (location: e.g., sigmoid colon, rectum, ascending colon) measuring (size in millimeters).  The polyp appears (description: e.g., erythematous, smooth, villous).  Polypectomy (or biopsy, if applicable) performed.  Pathological examination confirms the diagnosis of tubular adenoma.  Microscopic examination demonstrates low-grade dysplasia (or high-grade dysplasia if applicable).  Margins are (positive, negative, or close).  Assessment includes tubular adenoma of the colon, (size), (location).  Plan includes surveillance colonoscopy in (timeframe based on size, number, and histology of polyps) as per established guidelines.  Differential diagnoses considered included hyperplastic polyp, sessile serrated adenoma, and adenocarcinoma.  ICD-10 code D12.6 (Benign neoplasm of colon) is appropriate, along with relevant CPT codes for the colonoscopy and polypectomy (e.g., 45385, 45384, 45380 depending on the procedure performed).  Patient education provided regarding colon cancer screening guidelines, importance of follow-up, and lifestyle modifications for colorectal health.  Risks and benefits of surveillance colonoscopy discussed.  Patient verbalized understanding.