Find comprehensive information on thickened endometrium, including clinical documentation tips, medical coding guidelines (ICD-10), differential diagnosis considerations, ultrasound findings, and endometrial hyperplasia management. Learn about the causes of thickened uterine lining, diagnostic procedures, and treatment options. Explore resources for healthcare professionals, including pathology reports, clinical terminology, and best practices for accurate and efficient documentation of thickened endometrium cases.
Also known as
Endometrial hyperplasia
Abnormal thickening of the uterine lining (endometrium).
Other inflammatory diseases of uterus
Inflammation of the uterus not classified elsewhere, sometimes associated with thickening.
Ovarian dysfunction
Hormonal imbalances affecting ovaries can lead to endometrial thickening.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is endometrial thickening due to hyperplasia?
Yes
Is it atypical hyperplasia?
No
Is it due to hormonal effects?
When to use each related code
| Description |
|---|
| Thickened Endometrium |
| Endometrial Hyperplasia |
| Endometrial Polyp |
Coding thickened endometrium without specifying the cause (e.g., hormonal, polyp) leads to inaccurate reporting and potential denials. CDI crucial for clarification.
Missing or unclear documentation of atypia (if present) impacts coding, staging, and treatment. CDI should query for specificity in pathology reports.
Inconsistent endometrial thickness measurements across imaging reports can lead to coding errors. CDI should reconcile discrepancies for accurate coding.
Patient presents with abnormal uterine bleeding, including menorrhagia, metrorrhagia, or postmenopausal bleeding. Pelvic examination may reveal a normal-sized or enlarged uterus. Transvaginal ultrasound demonstrates endometrial thickening, measuring greater than the normal range for the patient's menopausal status. Differential diagnosis includes endometrial polyps, endometrial hyperplasia, and endometrial cancer. Endometrial biopsy or dilation and curettage is recommended to evaluate for endometrial pathology and determine the cause of the thickened endometrium. Clinical findings and ultrasound measurements are documented. Assessment includes thickened endometrium, abnormal uterine bleeding, and premenopausal or postmenopausal status as appropriate. Plan includes histopathological analysis of endometrial tissue, follow-up based on biopsy results, and consideration of hormonal therapy or further surgical intervention depending on the final diagnosis. Patient education provided regarding the importance of follow-up care and potential treatment options for endometrial hyperplasia or endometrial cancer if diagnosed. ICD-10 code N85.09, other specified noninflammatory disorders of uterus, may be considered depending on the specific clinical scenario, with further specification based on biopsy results. Medical coding and billing will be finalized based on the definitive diagnosis.