ICD-10 Coding for Endometrial Thickening(N85.00, R93.89)
Complete ICD-10-CM coding and documentation guide for Endometrial Thickening. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Endometrial Thickening
N85.0-N85.9Primary Range
Noninflammatory disorders of the endometrium
This range includes codes for various types of endometrial hyperplasia, which are common causes of endometrial thickening.
Abnormal findings on diagnostic imaging of other specified body structures
Used for imaging findings of endometrial thickening when hyperplasia is not confirmed.
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 without atypia | Use when biopsy confirms simple endometrial hyperplasia without atypia. |
|
| R93.89 | Abnormal findings on diagnostic imaging of other specified body structures | Use when imaging shows thickened endometrium but hyperplasia is not confirmed. |
|
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 thickening
Essential facts and insights about Endometrial Thickening
Primary ICD-10-CM Codes for endometrial thickening
Decision Criteria
clinical Criteria
- Biopsy confirms simple hyperplasia without atypia
Applicable To
- Simple endometrial hyperplasia without atypia
Excludes
- Endometrial hyperplasia with atypia (N85.01)
Clinical Validation Requirements
- Histological confirmation of hyperplasia without atypia
Code-Specific Risks
- Misuse without biopsy confirmation
Coding Notes
- Ensure biopsy confirmation before using this code.
R93.89 - Abnormal findings on diagnostic imaging of other specified body structures
Use when imaging shows thickened endometrium but hyperplasia is not confirmed.
Applicable To
- Thickened endometrium on imaging
Excludes
- Confirmed endometrial hyperplasia (N85.0x)
Clinical Validation Requirements
- Imaging report showing thickened endometrium
Coding Notes
Use this code for imaging findings pending further investigation.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Endometrial Thickening to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N85.00.
Impact
Clinical: Misleading diagnosis affecting treatment., Regulatory: Potential audit issues., Financial: Claim denials due to incorrect coding.
Mitigation Strategy
Verify biopsy results before coding., Educate staff on coding requirements.
Impact
Reimbursement: Incorrect DRG assignment leading to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Ensure biopsy confirms hyperplasia before coding N85.0x.
Impact
High risk of audit if hyperplasia coded without biopsy.
Mitigation Strategy
Implement mandatory biopsy documentation checks.
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 Thickening, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Endometrial Thickening
Use these documentation templates to ensure complete and accurate documentation for Endometrial Thickening. These templates include all required elements for proper coding and billing.
Postmenopausal endometrial thickening
Specialty: GynecologyRequired Elements
- Patient history
- Imaging findings
- Biopsy results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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