ICD-10 Coding for Endometrial Polyp(N84.0, N84.9)
Complete ICD-10-CM coding and documentation guide for Endometrial Polyp. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Endometrial Polyp
N84.0-N84.9Primary Range
Non-inflammatory disorders of female genital tract
This range includes codes for polyps in various locations of the female genital tract, including the endometrium.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N84.0 | Polyp of corpus uteri | Use when a polyp is confirmed in the corpus uteri, specifically the endometrium or myometrium. |
|
| N84.9 | Polyp of female genital tract, unspecified | Use when the location of the polyp is not specified after thorough investigation. |
|
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 polyp
Essential facts and insights about Endometrial Polyp
Primary ICD-10-CM Codes for endometrial polyp
Decision Criteria
clinical Criteria
- Histopathology confirms benign polyp
documentation Criteria
- Location of polyp is specified
Applicable To
- Endometrial polyp
- Myometrial polyp
Clinical Validation Requirements
- Histopathology confirming benign polyp
- Transvaginal ultrasound showing a feeding vessel
Code-Specific Risks
- Risk of using N84.9 if location is specified
- Excludes hyperplasia, requiring separate coding
Coding Notes
- Ensure documentation specifies the location within the uterus to avoid using unspecified codes.
N84.9 - Polyp of female genital tract, unspecified
Use when the location of the polyp is not specified after thorough investigation.
Applicable To
- Uterine polyp NOS
Clinical Validation Requirements
- Used only when specific location cannot be determined
Coding Notes
Avoid using if the location can be specified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Submucous leiomyoma of uterus
D25.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Endometrial hyperplasia
N85.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Endometrial Polyp to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N84.0.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of audit findings., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Educate clinicians on documentation requirements, Implement EHR prompts for location specification
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases audit risk due to lack of specificity., Data Quality: Reduces data accuracy and specificity.
Mitigation Strategy
Ensure documentation specifies the location to use a more specific code.
Impact
Using N84.9 when the location is known increases audit risk.
Mitigation Strategy
Ensure thorough documentation of polyp location.
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 Polyp, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Endometrial Polyp
Use these documentation templates to ensure complete and accurate documentation for Endometrial Polyp. These templates include all required elements for proper coding and billing.
Post-Polypectomy Documentation
Specialty: GynecologyRequired Elements
- Procedure details
- Histopathology results
- Follow-up plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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