Understanding Endometrial Mass (Uterine Mass) diagnosis, clinical documentation, and medical coding? Find information on Endometrial Lesion evaluation, treatment options, and healthcare best practices. Learn about relevant medical codes, diagnostic criteria, and documentation guidelines for Endometrial Mass in clinical settings. Explore resources for healthcare professionals related to Uterine Mass and Endometrial Lesion management.
Also known as
Leiomyoma of uterus
Benign smooth muscle tumors (fibroids) in the uterus.
Noninflammatory disorders of cervix
Cervical polyps, cysts, or other non-inflammatory conditions.
Other benign neoplasms of uterus
Benign growths in the uterus, excluding fibroids.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the endometrial mass malignant?
Yes
Type of endometrial cancer?
No
Is it an endometrial polyp?
When to use each related code
| Description |
|---|
| Thickening or growth in the uterine lining. |
| Benign growth within the uterine muscle. |
| Growth arising from the uterine muscle wall. |
Coding requires specifying if the mass is benign, malignant, or unspecified. Lack of clarity can lead to inaccurate coding and reimbursement.
Distinguishing between endometrial and uterine location is crucial for proper code assignment. Documentation must be precise.
Coding depends on the lesion type (e.g., polyp, hyperplasia). Insufficient documentation can lead to undercoding or unspecified codes.
Q: What is the optimal diagnostic approach for differentiating between benign and malignant endometrial masses in premenopausal women, considering factors like patient age, symptoms, and imaging findings?
A: Differentiating benign from malignant endometrial masses in premenopausal women requires a multi-faceted approach. Patient age, presenting symptoms (such as abnormal uterine bleeding, pelvic pain), and imaging characteristics on transvaginal ultrasound (TVUS) or MRI play crucial roles. For younger premenopausal women with a small, regular endometrial stripe and no concerning symptoms, expectant management with repeat imaging may be appropriate. However, for older premenopausal women or those with irregular bleeding, a thickened endometrium, or suspicious imaging features (e.g., heterogeneous echotexture, vascularity), endometrial biopsy is essential. Consider implementing a risk stratification algorithm based on these factors to guide decision-making. Explore how S10.AI can assist in risk assessment and diagnostic pathway selection for endometrial masses. Learn more about the latest diagnostic criteria for endometrial cancer.
Q: How can clinicians effectively use imaging (ultrasound, MRI) to assess endometrial mass size, location, and characteristics, and how do these findings inform management decisions like endometrial biopsy or hysteroscopy?
A: Imaging, particularly transvaginal ultrasound (TVUS) and MRI, is crucial for assessing endometrial masses. TVUS is often the first-line imaging modality, providing information on endometrial thickness, echogenicity, and the presence of any focal lesions. MRI offers higher resolution and can better characterize the mass, identifying features like myometrial invasion or cervical involvement. The size, location, and characteristics of the mass observed on imaging directly inform management decisions. A thickened endometrium ( 4mm in postmenopausal women or 12mm in premenopausal women) warrants further investigation, often with endometrial biopsy. Suspicious features on imaging like irregular borders or heterogeneous signal intensity increase the likelihood of malignancy and may necessitate hysteroscopy with directed biopsy for definitive diagnosis. Explore S10.AI's image analysis capabilities for enhanced accuracy in endometrial mass assessment. Consider implementing standardized imaging protocols to ensure consistent and reliable results. Learn more about the role of 3D ultrasound in evaluating endometrial lesions.
Patient presents with complaints suggestive of an endometrial mass, including abnormal uterine bleeding such as menorrhagia, metrorrhagia, or postmenopausal bleeding. Other presenting symptoms may include pelvic pain, pressure, or abnormal vaginal discharge. Physical examination findings may include an enlarged uterus or palpable mass on bimanual examination. Differential diagnosis includes endometrial polyps, endometrial hyperplasia, endometrial carcinoma, uterine fibroids, and adenomyosis. Transvaginal ultrasound was performed, revealing an endometrial thickening or a distinct endometrial mass measuring [measurement] cm. Given the patient's symptoms and ultrasound findings, an endometrial biopsy or dilation and curettage (D C) is recommended for histopathological evaluation to determine the nature of the mass and rule out malignancy. ICD-10 code D28.9 (Endometrial lesion, unspecified) is provisionally assigned pending definitive diagnosis. The patient was counseled on the findings and the need for further evaluation. Treatment options including hysteroscopy, endometrial ablation, or hysterectomy will be discussed upon receipt of pathology results. A follow-up appointment was scheduled to review the biopsy results and discuss the appropriate management plan. Medical necessity for the recommended procedures was explained, and appropriate pre-authorization for endometrial biopsy or D C will be obtained.