The ICD-10 code for rectal polyp is K62.1 Rectal polyp. Example: A 53-year-old-male presents for colonoscopy. There is a family history of colon polyps. The physician documents polyps of the colon, found during the examination.
Codes for benign adenomatous polyp of the colon are found in the neoplasm chapter of ICD-10-CM, by location: D12.0 Benign neoplasm of cecum D12.1 Benign neoplasm of appendix D12.2 Benign neoplasm of ascending colon
CPT 45383 is Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor (s), polyp (s), or other lesion (s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique. The description of this code is not as clear cut.
For malignant neoplasm (s) of the colon and rectum, refer to ICD-10 categories C18-C20. Example: A 70-year-old patient with a family history of colon cancer complains of abdominal pain and rectal bleeding. During colonoscopy, the physician finds a mass at the hepatic flexure, which pathology confirms as malignant.
hemorrhoids ( K64.-) A polypoid lesion that arises from the rectum and protrudes into the lumen. This group includes adenomatous polyps, serrated polyps, and hamartomatous polyps. This is a descriptive term referring of a mass of tissue that bulges or projects into the lumen of the rectum.
A type 1 excludes note is a pure excludes. It means "not coded here". A type 1 excludes note indicates that the code excluded should never be used at the same time as K62.1. A type 1 excludes note is for used for when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
CPT 45383 is Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor (s), polyp (s), or other lesion (s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
45380 is Colonoscopy with biopsy, single or multiple. Describes the use of forceps to grasp and remove a small piece of tissue without the application of cautery. The procedure note may describe the biopsy using cold biopsy forceps, or may not mention the device at all.
Dorland’s Medical Dictionary states: “antrum, pyloric is the dilated portion of the pyloric part of the stomach, distal to the body of the stomach and proximal to the pyloric canal.
The qualifier Diagnostic is used only for biopsies. A colonoscopy with biopsy of transverse colon is coded to root operation Excision and qualifier Diagnostic. If a colonoscopy is done to remove a polyp, and the polyp is sent to pathology, do NOT use qualifier X –diagnostic.
It is also called also gastric antrum and antrum of stomach… “pylorus, the distal aperture of the stomach, opening into the duodenum, variously used to mean pyloric part of the stomach and pyloric antrum, canal, opening or sphincter.”.