ICD-10 Coding for Uterine Enlargement(N85.2, D25.1)
Complete ICD-10-CM coding and documentation guide for Uterine Enlargement. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Enlargement
N85-N85.9Primary Range
Other noninflammatory disorders of uterus
This range includes codes for uterine hypertrophy and adenomyosis, common causes of uterine enlargement.
Leiomyoma of uterus
This range covers uterine fibroids, a frequent cause of uterine enlargement.
Maternal care for known or suspected abnormality of pelvic organs
Includes codes for pregnancy-related uterine enlargement.
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 when uterine enlargement is due to hypertrophy or adenomyosis without fibroids. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when uterine enlargement is due to fibroids. |
|
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 uterine enlargement
Essential facts and insights about Uterine Enlargement
Primary ICD-10-CM Codes for uterine enlargement
Decision Criteria
clinical Criteria
- Diffuse enlargement without nodules
Applicable To
- Adenomyosis
Excludes
- Fibroids (D25.-)
Clinical Validation Requirements
- Diffuse uterine enlargement without structural lesions
- Imaging showing myometrial thickening
Code-Specific Risks
- Misclassification with fibroids
Coding Notes
- Ensure imaging or clinical exam supports hypertrophy without fibroids.
D25.1 - Intramural leiomyoma of uterus
Use when uterine enlargement is due to fibroids.
Applicable To
- Fibroids
Excludes
- Adenomyosis (N85.2)
Clinical Validation Requirements
- Palpable firm nodules
- Imaging-confirmed fibroids
Coding Notes
Document fibroid type and location.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Abnormal findings on diagnostic imaging of other specified body structures
R93.89Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uterine Enlargement 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 affect surgical planning and outcomes., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Include uterine weight in operative reports., Train staff on documentation standards.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects accuracy of clinical data.
Mitigation Strategy
Specify whether enlargement is due to fibroids, adenomyosis, or other causes.
Impact
Risk of audits due to misclassification of uterine conditions.
Mitigation Strategy
Ensure thorough documentation and use of imaging to confirm diagnosis.
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 Uterine Enlargement, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Enlargement
Use these documentation templates to ensure complete and accurate documentation for Uterine Enlargement. These templates include all required elements for proper coding and billing.
Pelvic exam for suspected uterine enlargement
Specialty: GynecologyRequired Elements
- Uterine size
- Consistency
- Tenderness
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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