Understand endometrial polyp (uterine polyp, polyp of corpus uteri) diagnosis, clinical documentation, and medical coding. Find information on endometrial polyp symptoms, treatment, and ICD-10 codes for accurate healthcare records and billing. Learn about the diagnosis of uterine polyps, including clinical findings and medical coding best practices for endometrial polyps.
Also known as
Polyp of female genital tract
Codes for endometrial polyps and other female genital tract polyps.
Other noninflammatory disorders of uterus
Includes other uterine conditions not classified as inflammatory or neoplastic.
Leiomyoma of uterus
While not polyps, these are other common benign uterine growths.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the endometrial polyp symptomatic?
Yes
Is there irregular bleeding?
No
Code N84.0 (Polyp of corpus uteri)
When to use each related code
| Description |
|---|
| Benign growth in uterine lining. |
| Thickened uterine lining. |
| Cancerous growth in uterine lining. |
Coding endometrial polyp without specifying uterine body location can lead to claim denials. CDI should query for clarity.
Accurate documentation of atypia (or lack thereof) is crucial for proper coding and impacts medical necessity reviews.
Coding symptoms like abnormal uterine bleeding instead of confirmed endometrial polyp leads to undercoding and lost revenue.
Q: What are the most effective diagnostic strategies for differentiating between an endometrial polyp and other endometrial pathologies, such as endometrial hyperplasia or endometrial cancer, in premenopausal women?
A: Differentiating an endometrial polyp from other endometrial pathologies like endometrial hyperplasia or endometrial cancer in premenopausal women requires a multi-faceted approach. Transvaginal ultrasound (TVUS) is often the first-line imaging modality, but it can be challenging to distinguish between benign and malignant lesions based on ultrasound findings alone. Sonohysterography (SHG), also known as saline infusion sonography (SIS), can enhance the visualization of intrauterine abnormalities and improve diagnostic accuracy. Hysteroscopy with directed biopsy is considered the gold standard for definitive diagnosis. During hysteroscopy, the physician can directly visualize the endometrial cavity and obtain tissue samples for histopathological analysis, which is crucial for accurate diagnosis and determining the appropriate management strategy. Consider implementing a diagnostic algorithm that incorporates initial TVUS, followed by SHG or hysteroscopy with biopsy for cases with suspicious findings or persistent symptoms. Explore how integrating molecular markers or other advanced diagnostic techniques can further enhance the accuracy of endometrial polyp diagnosis. Learn more about the role of genetic testing in assessing the risk of malignant transformation in endometrial polyps.
Q: How should I manage asymptomatic endometrial polyps discovered incidentally during routine gynecological examinations in postmenopausal women, and when is surgical intervention warranted?
A: The management of asymptomatic endometrial polyps discovered incidentally in postmenopausal women often depends on factors like polyp size, patient symptoms (even if minimal), and patient preferences. While small, asymptomatic polyps may be managed expectantly with periodic surveillance via transvaginal ultrasound, larger polyps, particularly those greater than 1.5 cm, or those demonstrating suspicious ultrasound features warrant further evaluation. Consider hysteroscopy with polypectomy and histopathological analysis for definitive diagnosis and to rule out malignancy, especially given the increased risk of endometrial cancer in postmenopausal women. Explore how risk stratification models incorporating factors such as age, polyp size, and endometrial thickness can help guide management decisions. Even in asymptomatic cases, surgical intervention may be warranted if there's concern for potential malignant transformation or if the polyp is causing subtle, easily overlooked symptoms like irregular bleeding. Learn more about the long-term outcomes of expectant management versus surgical intervention for asymptomatic endometrial polyps in postmenopausal women.
Patient presents with abnormal uterine bleeding, specifically intermenstrual bleeding, menorrhagia, or postmenopausal bleeding. The patient complains of irregular periods and heavy menstrual flow, raising concerns for endometrial pathology. Transvaginal ultrasound revealed an endometrial thickening and a suspected endometrial polyp within the uterine cavity. Differential diagnoses include endometrial hyperplasia, submucosal fibroids, and endometrial cancer. To definitively diagnose the endometrial polyp and rule out malignancy, a hysteroscopy with endometrial biopsy was performed. Pathology confirmed the diagnosis of an endometrial polyp, showing benign endometrial glandular tissue. The patient's symptoms, ultrasound findings, and histopathology are consistent with the diagnosis of endometrial polyp of corpus uteri, also known as a uterine polyp. Treatment options, including polypectomy, hormonal therapy, and observation, were discussed with the patient. The chosen treatment plan is a hysteroscopic polypectomy to remove the polyp and alleviate symptoms. Follow-up will include a repeat ultrasound to assess the uterine cavity post-procedure and ongoing management of abnormal uterine bleeding if it persists. This documentation supports the medical necessity for the procedures performed and corresponds with ICD-10 code N84.0 for endometrial polyp and CPT codes for the hysteroscopy and biopsy, ensuring accurate medical billing and coding.