Understanding uterine enlargement? Find information on diagnosis codes (ICD-10), clinical documentation requirements, differential diagnoses, and common causes of an enlarged uterus including pregnancy, fibroids, adenomyosis, and leiomyomas. This resource offers guidance for healthcare professionals on proper medical coding and documentation for uterine enlargement in clinical practice. Explore related terms like uterine hypertrophy, enlarged womb, and uterine size increase.
Also known as
Noninflammatory disorders of female genital tract
Covers various uterine conditions, including enlargement.
Pregnancy, childbirth and the puerperium
Uterine enlargement is a normal part of pregnancy.
Symptoms and signs involving the abdomen and pelvis
May include abdominal distension related to uterine enlargement.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the uterine enlargement due to pregnancy?
Yes
Code as appropriate obstetric code (e.g., O00-O9A). Do not code uterine enlargement separately.
No
Is there a leiomyoma (fibroid) present?
When to use each related code
| Description |
|---|
| Uterine Enlargement |
| Pregnancy |
| Uterine Fibroids |
Coding uterine enlargement without specifying the cause (e.g., pregnancy, fibroids) leads to inaccurate reporting and potential denials. Impacts CDI queries and quality metrics.
Relying on imprecise uterine size descriptions instead of quantifiable measurements (e.g., cm) can affect coding specificity and reimbursement. Important for audits.
Coding uterine enlargement without supporting clinical documentation (e.g., physical exam, imaging) increases compliance risks and claim denials. Crucial for medical coding accuracy.
Patient presents with uterine enlargement, also documented as an enlarged uterus, uterine hypertrophy, or increased uterine size. Physical examination revealed a palpable, enlarged uterus extending beyond the expected size for gestational age if pregnant, or larger than normal for a non-pregnant uterus. Differential diagnosis includes pregnancy, uterine fibroids (leiomyomas), adenomyosis, uterine polyps, pelvic inflammatory disease, uterine cancer (endometrial carcinoma, uterine sarcoma), and ovarian masses. Patient reports (insert relevant symptoms such as pelvic pain, pressure, abnormal uterine bleeding, menorrhagia, dysmenorrhea, bloating, abdominal distension, or infertility). Pelvic examination findings include (describe size, shape, consistency, and mobility of the uterus). Ultrasound imaging of the uterus and ovaries was ordered to evaluate the cause of the uterine enlargement. Laboratory tests, including a complete blood count (CBC), human chorionic gonadotropin (hCG) to rule out pregnancy, and other relevant hormone levels may be obtained. Further evaluation may include magnetic resonance imaging (MRI) of the pelvis if indicated. The diagnosis, ICD-10 code (e.g., N85.89 Other specified noninflammatory disorders of uterus, except cervix), and treatment plan will be determined based on imaging and laboratory results. Patient education was provided regarding potential causes, diagnostic procedures, and treatment options for uterine enlargement. Follow-up appointment scheduled for (date) to discuss results and management plan.