ICD-10 Coding for Personal History of Polyps with EGD
For a patient with a personal history of gastrointestinal polyps undergoing EGD, use Z86.010 (personal history of colonic polyps) or Z87.19 (personal history of other diseases of the digestive system) as the indication code, and code any polyps found during the exam based on their specific location, size, morphology, and histology using the appropriate K-series codes.
Coding the Indication (Personal History)
When coding the indication for EGD in a patient with a history of polyps:
- Z86.010: Personal history of colonic polyps (if the history specifically involves colon)
- Z87.19: Personal history of other diseases of the digestive system (for gastric/duodenal polyp history)
- Z80.0: Family history of malignant neoplasm of digestive organs (if relevant to indication)
These "Z" codes establish medical necessity for the procedure and should be listed as the primary indication.
Coding Polyps Found During EGD
When polyps are identified during the examination, document and code based on the comprehensive endoscopic findings 1:
Required Documentation Elements
For each polyp identified, document:
- Number: Actual count if ≤5 polyps; "multiple polyps" acceptable if >5 1
- Size: Maximum diameter in millimeters
- Location: Specific anatomic site (esophagus, gastric fundus/body/antrum, duodenum)
- Morphology: Sessile, pedunculated, or flat
- Histology: After biopsy/resection (fundic gland, hyperplastic, adenomatous, etc.)
Specific ICD-10 Codes for Gastric Polyps
- K31.7: Polyp of stomach and duodenum (general code)
- D13.1: Benign neoplasm of stomach (for confirmed benign polyps)
- K31.89: Other diseases of stomach and duodenum (for specific polyp types after histology)
Coding by Polyp Type (After Histology)
- Generally code as K31.7
- Document if >1 cm (higher dysplasia risk: 1.9%)
- Note PPI use if relevant
- Consider FAP if >20 polyps or patient <40 years
- Code as K31.7 initially
- Document size (dysplasia risk if >1 cm: 1.9-19%)
- Note H. pylori status
- Code K29.4 if associated chronic atrophic gastritis present
Adenomatous polyps:
- D13.1 for benign gastric adenoma
- Document dysplasia grade if present
- Consider polyposis syndrome if multiple
Coding Biopsies and Interventions
- 45.16: Esophagogastroduodenoscopy [EGD] with biopsy (CPT 43239)
- 45.13: EGD with removal of lesion by snare (CPT 43251)
- Document whether complete or incomplete resection
Surveillance Interval Coding Implications
The histology determines follow-up coding 1, 3, 4:
Low-risk findings (1-2 small tubular adenomas <1 cm):
- Next surveillance: 5-10 years
- Code subsequent encounters with Z12.11 (encounter for screening for malignant neoplasm of colon) or Z86.010
Advanced adenomas (≥1 cm, high-grade dysplasia, villous features):
- Next surveillance: 3 years
- Code with Z86.010 and specify advanced features
Dysplastic polyps:
- Low-grade dysplasia: 6-month follow-up if incomplete resection, 1 year if complete 5
- High-grade dysplasia: 3-month follow-up if incomplete, 6 months if complete 5
Common Pitfalls to Avoid
Don't use R19.5 (abnormal fecal test) for polyp history—this is specific to FIT-positive patients 6
Don't code based on endoscopic appearance alone—wait for histology to assign specific polyp type codes 1
Don't forget to code associated conditions:
- H. pylori (B96.81) if present
- Chronic gastritis (K29.x series)
- PPI use (Z79.899 for long-term drug therapy)
Document FAP screening if multiple polyps present—30-50% of FAP patients have gastric adenomas and up to 90% have duodenal adenomas 1, 4
For incomplete colonoscopy leading to EGD, code the incomplete procedure and reason separately
Special Populations
Familial adenomatous polyposis 4:
- Code D12.6 (benign neoplasm of colon, multiple sites) if FAP confirmed
- Annual surveillance required
- Document duodenal evaluation (90% have duodenal adenomas)
Peutz-Jeghers syndrome 7:
- Code Q85.8 (other phakomatoses)
- EGD surveillance every 2-3 years starting age 8-10
- Document hamartomatous polyp characteristics