ICD-10 Coding for Endometrial Hyperplasia(N85.00, N85.01, N85.02)
Complete ICD-10-CM coding and documentation guide for Endometrial Hyperplasia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Endometrial Hyperplasia
N85.00-N85.02Primary Range
Endometrial hyperplasia codes
These codes are used to classify different types of endometrial hyperplasia based on biopsy confirmation.
Abnormal findings on diagnostic imaging of other specified body structures
Used when imaging shows endometrial thickening without biopsy confirmation.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N85.00 | Endometrial hyperplasia, unspecified | Use when biopsy confirms hyperplasia but does not specify type. |
|
| N85.01 | Benign endometrial hyperplasia without atypia | Use when biopsy confirms benign hyperplasia without atypia. |
|
| N85.02 | Endometrial intraepithelial neoplasia (EIN) | Use when biopsy confirms hyperplasia with atypia. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for endometrial hyperplasia
Essential facts and insights about Endometrial Hyperplasia
Primary ICD-10-CM Codes for endometrial hyperplasia
Decision Criteria
clinical Criteria
- Biopsy confirms hyperplasia but type is unspecified
Applicable To
- Unspecified endometrial hyperplasia
Excludes
- Endometrial cancer
Clinical Validation Requirements
- Biopsy confirmation required
Code-Specific Risks
- Risk of incorrect coding if used without biopsy confirmation
Coding Notes
- Ensure biopsy confirmation before using this code.
N85.01 - Benign endometrial hyperplasia without atypia
Use when biopsy confirms benign hyperplasia without atypia.
Applicable To
- Simple endometrial hyperplasia without atypia
Excludes
- Endometrial cancer
Clinical Validation Requirements
- Biopsy confirmation required
Coding Notes
Ensure biopsy confirms absence of atypia.
N85.02 - Endometrial intraepithelial neoplasia (EIN)
Use when biopsy confirms hyperplasia with atypia.
Applicable To
- Complex hyperplasia with atypia
Excludes
- Endometrial cancer
Clinical Validation Requirements
- Biopsy confirmation required
Coding Notes
Ensure biopsy confirms presence of atypia.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long term (current) use of selective estrogen receptor modulators (SERMs)
Z79.810Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Endometrial Hyperplasia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N85.00.
Impact
Clinical: Misrepresentation of patient's condition, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Verify biopsy results before coding, Educate staff on documentation requirements
Impact
Reimbursement: May result in claim denial, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Use R93.89 for imaging findings without biopsy confirmation
Impact
Coding hyperplasia without biopsy confirmation
Mitigation Strategy
Ensure biopsy results are documented before coding
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Endometrial Hyperplasia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Endometrial Hyperplasia
Use these documentation templates to ensure complete and accurate documentation for Endometrial Hyperplasia. These templates include all required elements for proper coding and billing.
Gynecology Clinic Note
Specialty: GynecologyRequired Elements
- Chief Complaint
- History
- Imaging
- Biopsy
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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