Benign neoplasm of colon, rectum, anus and anal canal
Chapter 2:Neoplasms
ICD-10 D12 is a billable code used to indicate a diagnosis of benign neoplasm of colon, rectum, anus and anal canal.
Benign neoplasms of the colon, rectum, anus, and anal canal are non-cancerous growths that can occur in these areas of the gastrointestinal tract. These neoplasms may include adenomatous polyps, hyperplastic polyps, and other types of benign tumors. While they are not malignant, some benign neoplasms, particularly adenomatous polyps, have the potential to progress to colorectal cancer if left untreated. Regular surveillance through colonoscopy is often recommended for patients with a history of these neoplasms to monitor for any changes that may indicate malignancy. The clinical presentation can vary, with some patients being asymptomatic while others may experience symptoms such as rectal bleeding or changes in bowel habits. Diagnosis typically involves imaging studies and histological examination of biopsy samples. Management may include surveillance, polypectomy, or surgical intervention depending on the size, type, and number of neoplasms present.
Detailed descriptions of the neoplasm type, size, and location, along with any relevant imaging or biopsy results.
Patients presenting for routine surveillance colonoscopy, patients with a history of polyps, and those experiencing gastrointestinal symptoms.
Documentation must clearly indicate the benign nature of the neoplasm and any recommendations for follow-up or intervention.
Operative reports detailing the excision of neoplasms, including size, type, and histopathological findings.
Patients undergoing polypectomy or surgical resection of benign neoplasms.
Ensure that the surgical indication is clearly documented to support the coding of the procedure.
Used for surveillance of benign neoplasms in patients with a history of polyps.
Documentation must include indications for the procedure and findings.
Gastroenterologists should ensure that the reason for surveillance is clearly documented.
Coding D12 is crucial for tracking benign neoplasms that may require surveillance due to their potential to progress to colorectal cancer. Accurate coding ensures appropriate management and follow-up for patients.
