ICD-10 Coding for Thickening of the Endometrium(R93.89, N85.00)
Complete ICD-10-CM coding and documentation guide for Thickening of the Endometrium. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Thickening of 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 |
|---|---|---|---|
| R93.89 | Abnormal findings on diagnostic imaging of other specified body structures | Use when endometrial thickening is noted on imaging without biopsy confirmation of hyperplasia. |
|
| N85.00 | Endometrial hyperplasia, unspecified | Use when hyperplasia is confirmed by biopsy. |
|
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 thickening of the endometrium
Essential facts and insights about Thickening of the Endometrium
Primary ICD-10-CM Codes for thickening of the endometrium
Decision Criteria
clinical Criteria
- Endometrial thickness ≥5 mm on TVUS in postmenopausal women
documentation Criteria
- Absence of biopsy confirmation for hyperplasia
Applicable To
- Incidental finding of endometrial thickening
Excludes
- Confirmed endometrial hyperplasia (N85.0-)
Clinical Validation Requirements
- Ultrasound showing endometrial thickness ≥5 mm in postmenopausal women without bleeding
Code-Specific Risks
- Incorrectly using this code for confirmed hyperplasia can lead to audit issues.
Coding Notes
- Ensure documentation specifies 'thickening' without terms like 'hyperplasia' unless confirmed.
N85.00 - Endometrial hyperplasia, unspecified
Use when hyperplasia is confirmed by biopsy.
Applicable To
- Confirmed endometrial hyperplasia
Excludes
- Incidental endometrial thickening (R93.89)
Clinical Validation Requirements
- Biopsy report confirming hyperplasia
Coding Notes
Ensure biopsy confirmation is documented before using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for other preprocedural examination
Z01.818Differential 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 Thickening of the 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 vague clinical records., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Use specific terms like 'endometrial thickness of X mm'., Ensure biopsy results are documented if applicable.
Impact
Reimbursement: Incorrect DRG assignment can affect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R93.89 for imaging findings and reserve N85.00 for confirmed cases.
Impact
Using N85.00 without biopsy confirmation can trigger audits.
Mitigation Strategy
Ensure biopsy confirmation is 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 Thickening of the Endometrium, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Thickening of the Endometrium
Use these documentation templates to ensure complete and accurate documentation for Thickening of the Endometrium. These templates include all required elements for proper coding and billing.
Postmenopausal Screening
Specialty: GynecologyRequired Elements
- Patient age and menopausal status
- Ultrasound findings
- Biopsy results if applicable
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Thickening of the Endometrium? Ask your questions below.