ICD-10 Coding for Endometrial Biopsy(N85.00, N85.02)
Complete ICD-10-CM coding and documentation guide for Endometrial Biopsy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Endometrial Biopsy
N85.00-N85.05Primary Range
Endometrial hyperplasia
This range includes codes for various types of endometrial hyperplasia, which are common findings in endometrial biopsy results.
Postmenopausal bleeding
Postmenopausal bleeding is a common indication for performing an endometrial biopsy.
Cervical stenosis
Cervical stenosis may necessitate cervical dilation during an endometrial biopsy procedure.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N85.00 | Endometrial hyperplasia, unspecified | Use when biopsy results indicate hyperplasia without further specification. |
|
| N85.02 | Simple endometrial hyperplasia without atypia | Use when biopsy results specify simple 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 endometrial biopsy
Essential facts and insights about Endometrial Biopsy
Primary ICD-10-CM Codes for endometrial biopsy
Decision Criteria
clinical Criteria
- Biopsy confirms hyperplasia without atypia.
Applicable To
- Endometrial hyperplasia without further specification
Excludes
- Endometrial hyperplasia with atypia
Clinical Validation Requirements
- Histopathological confirmation of hyperplasia without atypia
Code-Specific Risks
- May lead to under-coding if atypia is present but not documented.
Coding Notes
- Ensure biopsy results are reviewed for specificity.
N85.02 - Simple endometrial hyperplasia without atypia
Use when biopsy results specify simple hyperplasia without atypia.
Applicable To
- Simple hyperplasia without atypia
Excludes
- Complex hyperplasia with atypia
Clinical Validation Requirements
- Biopsy results confirming simple hyperplasia
Coding Notes
Review pathology report for accurate coding.
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 Endometrial Biopsy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N85.00.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding guidelines., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Ensure procedure notes include all steps performed.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with CCI edits., Data Quality: Inaccurate procedure data.
Mitigation Strategy
Use 58120 if cervical dilation is performed.
Impact
Incomplete documentation of procedure details may lead to audit findings.
Mitigation Strategy
Ensure comprehensive documentation of all procedural steps.
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 Endometrial Biopsy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Endometrial Biopsy
Use these documentation templates to ensure complete and accurate documentation for Endometrial Biopsy. These templates include all required elements for proper coding and billing.
Endometrial biopsy for postmenopausal bleeding
Specialty: GynecologyRequired Elements
- Indication for biopsy
- Procedure details
- Findings
- Pathology results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Endometrial Biopsy? Ask your questions below.