Improve Your Hyperplasia Diagnosis Coding Skills Before Oct. 2013 Hits

You won't find one-to-one matches for all your existing ICD-9 codes.

In case a pathology report comes back along with a hyperplasia diagnosis, then there are five possible ICD-9 codes you can report. On the other hand, in ICD-10, you'll only have three choices.

Hyperplasia defined: When hyperplasia takes place, this means the patient has a rise in the number of cells. In the instance of endometrial hyperplasia, this implies that the cells have multiplied in the endometrium, or the inner lining of the uterus.

An endometrial intraepithelial neoplasm is essentially a precancerous lesion in the endometrium that makes the uterine lining more prone to endometroid endometrial adenocarcinoma.

ICD-9-CM Codes: Here are the ICD-9 codes that apply:

621.30 (Endometrial hyperplasia, unspecified)

621.31 (Simple endometrial hyperplasia without atypia)

621.32 (Complex endometrial hyperplasia without atypia)

621.33 (Endometrial hyperplasia with atypia)

621.35 (Endometrial intraepithelial neoplasia [EIN])

ICD-10-CM Codes:

N85.00 (Endometrial hyperplasia, unspecified)

N85.01 (Benign endometrial hyperplasia)

N85.02 (Endometrial intraepithelial neoplasm [EIN])

ICD-10 Change: In the incident of 621.30 and 621.31, you have a one-to-one relationship between your ICD-9 codes and ICD-10 counterparts (N85.00 and N85.01 respectively). Though, ICD-10 rolls 621.32, 621.33, and 621.35 into N85.02.

Documentation: Additional terms for N85.00 contain "hyperplasia (adenomatous) (cystic) (glandular) of endometrium" and "hyperplastic endometritis." A note listed beneath N85.01 includes "endometrial hyperplasia (complex) (simple) excluding atypia. Furthermore, another note under N85.02 is "endometrial hyperplasia with atypia."

Watch out: Assume the provider doubts hyperplasia. He identifies and documents "endometrial thickening" in an ultrasound examination. What diagnosis should you report? JSimply because the provider documents endometrial thickening does not imply that the patient actually has endometrial hyperplasia. A lot of coders make this mistake. You must not code this as hyperplasia as physicians don't always take the thickening of the uterus "abnormal;" in fact; it's simply a monthly "ramp up" for all women. For ICD10, this condition has been referred to R93.8 (Abnormal findings on diagnostic imaging of other specified body structures). You will discover this in the index by searching the term "thickening, endometrium.

Medical Billing and Coding Tips: You should not report hyperplasia until the provider has executed a biopsy, and you have a pathology report that confirms this condition.

ICD-9-CM to ICD-10-CM Transition Update: You have an Excludes1 note in the N85.-- classification, you'll see an Excludes1 note that prevents you from reporting these codes with endometriosis (N80.-), inflammatory diseases of uterus (N71-), noninflammatory disorders of cervix, excluding malposition (N86-N88), polyp of corpus uteri (N84.0), plus uterine prolapse (N81-).

You'll also discover another Excludes1 note under N85.02 preventing you from reporting this particular code with malignant neoplasm of endometrium (with endometrial intraepithelial neoplasia [EIN]) (C54.1).