benign neoplasm of colon

when a physician notes in his diagnosis tubular adenoma with displasia s/p colonoscopy 9/-7 and doesnt mention in the note anything about it do we code as a diagnosis benign neoplasm of the colon??? thank you very much . I think not but co-workers usually do.

Adenoma

An adenoma is a benign tumor that develops from epithelial tissue. Adenomas in the colon are often referred to as adenomatous polyps. Tubular adenoma is the most common type of adenomatous polyp of the colon, with tubules highly variable in size and often occurring singly.

neoplasm

It is a benign growth from the neoplasm table/by site in ICD-9-CM Vol. 2. Verify in Vol. 1.

I interpret the question differently

here's a rough version what the writer is asking- The doc writes a note- here for HTN. Had adenoma excised at colonoscopy. Exam- normal, bp 120/80 plan- cont BP med. The question is - do you include benign noplasm of colon as a diagnosis attached to 99213 along with 401.1?

colon adenoma

my question is do we code v12.72 for an adenoma found in 2007 making the assumption that it was removed...some of my co-workers are coding the adenoma on subsequent e&m visits instead of v12.72---

personal History code

If the adenoma was removed and it is no longer present nor is the patient receiving treatment for the condition, then it is a Personal History Of.... V code assignment.

colon adenoma

the subsequent primary physicians note said colon adenoma s/p colonoscopy 2007---i am asking if we code the adenoma or the v12.72 or just ignore the diagnosis with only that info to go on. no current treatment is mentioned. i thought it would be asumed in this instance to be a history and my co-workers are coding the adenoma itself...sorry to be unclear...

My guess is...

don't code it since it was just mentioned, BUT if she says "colonoscopy due this year" then it is a Management and I would put it in my diagnosis list. I would probably use 211.3 not the V code since it is an active "problem".

211.3 vs V12.72

At our gastro office we would use 211.3 benign neoplasm if a polyp was found during an active colonscopy, whether it was removed or not. If it was not removed and the patient had a colonoscopy within a year we would still use 211.3 because nothing has been done to the polyp. If it was removed it would forever be referred to a V12.72.