ICD-10 Coding for Thickened Endometrium(R93.89, N85.00)
Complete ICD-10-CM coding and documentation guide for Thickened Endometrium. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Thickened Endometrium
N85.00-N85.05Primary Range
Endometrial hyperplasia codes
These codes are used for confirmed cases of endometrial hyperplasia, with or without atypia.
Abnormal findings on diagnostic imaging of other specified body structures
Used for abnormal imaging findings of the endometrium without a confirmed diagnosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R93.89 | Abnormal findings on diagnostic imaging of other specified body structures | Use when imaging shows thickened endometrium without biopsy confirmation of hyperplasia. |
|
| N85.00 | Endometrial hyperplasia without atypia | Use when biopsy confirms hyperplasia without 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 thickened endometrium
Essential facts and insights about Thickened Endometrium
Primary ICD-10-CM Codes for thickened endometrium
Decision Criteria
clinical Criteria
- Imaging shows endometrial thickening without biopsy confirmation.
Applicable To
- Abnormal ultrasound findings of the endometrium
Excludes
- Confirmed endometrial hyperplasia
Clinical Validation Requirements
- Ultrasound showing endometrial thickness >4mm in postmenopausal women or >16mm in premenopausal women
Code-Specific Risks
- Misclassification as hyperplasia without biopsy confirmation
Coding Notes
- Ensure imaging findings are documented clearly without assuming hyperplasia.
N85.00 - Endometrial hyperplasia without atypia
Use when biopsy confirms hyperplasia without atypia.
Applicable To
- Simple hyperplasia without atypia
Excludes
- Endometrial hyperplasia with atypia
Clinical Validation Requirements
- Biopsy confirming simple or complex hyperplasia without atypia
Coding Notes
Biopsy results must be documented to confirm the absence of atypia.
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 Thickened Endometrium to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R93.89.
Impact
Clinical: Leads to misdiagnosis and inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Always include specific imaging and biopsy findings., Use templates to ensure comprehensive documentation.
Impact
Reimbursement: Incorrect DRG assignment leading to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Use R93.89 for imaging findings without biopsy confirmation.
Impact
Risk of coding thickened endometrium as hyperplasia without biopsy.
Mitigation Strategy
Require biopsy confirmation before coding hyperplasia.
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 Thickened Endometrium, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Thickened Endometrium
Use these documentation templates to ensure complete and accurate documentation for Thickened Endometrium. These templates include all required elements for proper coding and billing.
Postmenopausal bleeding with thickened endometrium
Specialty: GynecologyRequired Elements
- Menopausal status
- Ultrasound findings
- Biopsy results
- Risk factors
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Thickened Endometrium? Ask your questions below.