ICD-10 Coding for Proliferative Endometrium(N85.8, Z01.4)
Complete ICD-10-CM coding and documentation guide for Proliferative Endometrium. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Proliferative 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 |
|---|---|---|---|
| N85.8 | Other specified noninflammatory disorders of uterus | Use when biopsy confirms disordered proliferative endometrium. |
|
| Z01.4 | Encounter for gynecological examination | Use for routine exams where proliferative endometrium is noted without symptoms. |
|
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 disordered proliferative endometrium
Essential facts and insights about Proliferative Endometrium
Primary ICD-10-CM Codes for proliferative endometrium
Decision Criteria
clinical Criteria
- Biopsy shows glandular crowding with gland:stroma ratio <1:1
documentation Criteria
- Document absence of atypia and presence of irregular bleeding
Clinical Validation Requirements
- Biopsy showing glandular crowding with gland:stroma ratio <1:1
- Irregular bleeding without atypia
Code-Specific Risks
- Confusing with endometrial hyperplasia codes
Coding Notes
- Ensure biopsy results support the diagnosis of disordered proliferative endometrium.
Z01.4 - Encounter for gynecological examination
Use for routine exams where proliferative endometrium is noted without symptoms.
Applicable To
- Routine gynecological exam
Excludes
- Exams with abnormal findings (N85.8)
Clinical Validation Requirements
- Routine exam without symptoms
Coding Notes
Do not use if symptoms or abnormal findings are present.
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.
Endometrial hyperplasia without atypia
N85.00Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Proliferative Endometrium to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N85.8.
Impact
Clinical: Misdiagnosis risk, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Ensure biopsy reports are detailed, Include all relevant clinical findings
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Verify biopsy results to ensure correct gland:stroma ratio and absence of atypia.
Impact
Inadequate biopsy documentation can lead to coding errors.
Mitigation Strategy
Ensure all biopsy findings are clearly documented.
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 Proliferative Endometrium, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Proliferative Endometrium
Use these documentation templates to ensure complete and accurate documentation for Proliferative Endometrium. These templates include all required elements for proper coding and billing.
Patient with irregular bleeding
Specialty: GynecologyRequired Elements
- Biopsy findings
- Clinical symptoms
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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