ICD-10 Coding for Uterine Polyp(N84.0, D28.2)
Complete ICD-10-CM coding and documentation guide for Uterine Polyp. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Polyp
N84.0-N84.9Primary Range
Non-neoplastic lesions of uterus
This range includes codes for various types of uterine polyps, including endometrial polyps.
Benign neoplasms of uterus
This range includes codes for adenomatous polyps, which are benign neoplasms of the uterus.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N84.0 | Polyp of corpus uteri | Use when a polyp is confirmed in the corpus uteri without neoplastic features. |
|
| D28.2 | Benign neoplasm of uterus | Use when a polyp is confirmed as adenomatous via 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 uterine polyp
Essential facts and insights about Uterine Polyp
Primary ICD-10-CM Codes for uterine polyp
Decision Criteria
clinical Criteria
- Confirmed benign polyp via imaging or pathology
coding Criteria
- Avoid using for adenomatous or hyperplastic polyps
Applicable To
- Endometrial polyps
- Uterine polyps NOS
Clinical Validation Requirements
- Imaging confirmation via ultrasound or hysteroscopy
- Histopathology reports confirming benign nature
Code-Specific Risks
- Confusion with hyperplasia or adenomatous polyps leading to incorrect coding.
Coding Notes
- Ensure documentation specifies the location and nature of the polyp to avoid miscoding.
D28.2 - Benign neoplasm of uterus
Use when a polyp is confirmed as adenomatous via biopsy.
Applicable To
- Adenomatous polyps
Excludes
- Non-neoplastic polyps (N84.0)
Clinical Validation Requirements
- Histology report confirming adenomatous or neoplastic nature
Coding Notes
Ensure biopsy confirms adenomatous nature before using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Abnormal uterine bleeding
N92.0-N93.9Postmenopausal bleeding
N95.0Differential 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 Uterine Polyp to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N84.0.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Increases risk of audit discrepancies., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Use specific terminology in reports, Ensure all findings are confirmed with imaging or pathology
Impact
Reimbursement: Incorrect coding can lead to incorrect DRG assignment., Compliance: May result in audit issues if coding does not match documentation., Data Quality: Affects the accuracy of clinical data and patient records.
Mitigation Strategy
Verify biopsy results to confirm adenomatous nature before coding.
Impact
Using N84.0 for adenomatous polyps or vice versa.
Mitigation Strategy
Verify pathology reports before finalizing code.
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 Polyp, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Polyp
Use these documentation templates to ensure complete and accurate documentation for Uterine Polyp. These templates include all required elements for proper coding and billing.
Postmenopausal Bleeding with Polyp
Specialty: GynecologyRequired Elements
- Patient age and menopausal status
- Symptoms and duration
- Imaging findings
- Pathology results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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