ICD-10 Coding for Enlarged Uterus(N85.2, O26.84-)
Complete ICD-10-CM coding and documentation guide for Enlarged Uterus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Enlarged Uterus
N85-N85.9Primary Range
Other noninflammatory disorders of uterus
This range includes codes for non-pregnancy related uterine conditions such as hypertrophy.
Uterine size-date discrepancy in pregnancy
This range is used for pregnancy-related uterine enlargement without fetal growth issues.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N85.2 | Hypertrophy of uterus | Use for non-pregnant patients with documented uterine enlargement. |
|
| O26.84- | Uterine size-date discrepancy in pregnancy | Use during pregnancy when fundal height is greater than expected for gestational age. |
|
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 enlarged uterus
Essential facts and insights about Enlarged Uterus
Primary ICD-10-CM Codes for enlarged uterus
Decision Criteria
clinical Criteria
- Uterine enlargement confirmed by imaging in a non-pregnant patient.
documentation Criteria
- Clear documentation of non-pregnancy and associated symptoms.
Applicable To
- Non-pregnant uterine enlargement
Excludes
- Uterine size-date discrepancy in pregnancy (O26.84-)
Clinical Validation Requirements
- Ultrasound or MRI confirming uterine enlargement
- Documentation of non-pregnancy status
- Associated symptoms like pelvic pain or heavy bleeding
Code-Specific Risks
- Confusion with pregnancy-related codes
- Lack of specificity in documentation
Coding Notes
- Ensure documentation specifies non-pregnancy status and any underlying causes.
O26.84- - Uterine size-date discrepancy in pregnancy
Use during pregnancy when fundal height is greater than expected for gestational age.
Applicable To
- Pregnancy-related uterine enlargement without fetal growth issues
Excludes
- Hypertrophy of uterus (N85.2)
Clinical Validation Requirements
- Fundal height measurements showing discrepancy
- Ultrasound confirming normal fetal growth
Coding Notes
Ensure documentation includes fundal height and gestational age.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Enlarged Uterus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N85.2.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Potential for audit issues due to insufficient documentation., Financial: Incorrect coding can affect reimbursement rates.
Mitigation Strategy
Ensure imaging reports include detailed uterine measurements., Document all relevant clinical findings and symptoms.
Impact
Reimbursement: Incorrect DRG assignment leading to reimbursement issues., Compliance: Potential audit flags for incorrect coding., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Verify pregnancy status and use O26.84- only when uterine enlargement is due to pregnancy.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Lack of specificity in patient records.
Mitigation Strategy
Document underlying causes such as fibroids or adenomyosis.
Impact
Using O26.84- for non-pregnant patients.
Mitigation Strategy
Verify pregnancy status 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 Enlarged Uterus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Enlarged Uterus
Use these documentation templates to ensure complete and accurate documentation for Enlarged Uterus. These templates include all required elements for proper coding and billing.
Non-pregnant patient with uterine hypertrophy
Specialty: GynecologyRequired Elements
- Patient history
- Pelvic examination findings
- Imaging results
- Associated symptoms
- Differential diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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