Certified Coding Specialist (CCS) Practice Exam

When a polypectomy is performed during a screening colonoscopy, it is essential to report both the screening indication and the specific diagnosis related to the findings during the procedure. The code Z12.11 is used to indicate a screening for malignant neoplasm of the colon, which is appropriate in the context of a screening colonoscopy. D12.6, on the other hand, is the code for a neoplasm of uncertain behavior of the colon (specifically, a benign neoplasm such as a polyp).

Using both codes—Z12.11 for the screening aspect and D12.6 to indicate the presence of a colon polyp—provides a complete and compliant coding scenario that reflects the reason for the colonoscopy and the result. It highlights the preventive nature of the procedure and also indicates a finding that necessitates reporting for follow-up or further management if necessary.

Combining these codes ensures that the medical necessity is well-documented, supporting proper billing and potential reimbursement for the services rendered.