Ob-Gyn Coding Alert

If you're scratching your head when your physician documents "endometrial thickening," you're not alone.

Tackle this common scenario, avoid this major pitfall, and you'll be applying the correct diagnosis every time.

Scenario: Your ob-gyn suspects hyperplasia. He detects and documents "endometrial thickening" during an ultrasound examination. What diagnosis should you report?

Just because your ob-gyn documents endometrial thickening does not mean the patient has endometrial hyperplasia (621.30, Endometrial hyperplasia, unspecified; or 621.31, Simple endometrial hyperplasia without atypia). Many coders make this mistake.

ICD-10: When you report hyperplasia in 2013, you'll use the straight forward equivalents N8500 (Endometrial hyperplasia, unspecified) and N8501 (Simple endometrial hyperplasia without atypia).

"You should not code this as hyperplasia because physicians don't [necessarily] consider the thickening of the uterus 'abnormal;' in fact, it's just a monthly 'ramp up' for all women," says Tara Onder, CPC, ob-gyn specialtycoder for the Vancouver Clinic in Wash.

Important: If the patient requires more diagnostic tests because she presents with conditions that would increase the risk of hyperplasia, then you should report the ICD-9 codes that describe these conditions. For instance, you would report morbid obesity as 278.01.

To indicate that a patient was currently taking Tamoxifen (an estrogen antagonist), you would report V07.51 (Prophylactic use of selective estogen receptor modulators [SERMS]). Of course, the patient would not be taking Tamoxifen unless she was estrogen-receptor positive, so you would also report V86.0 (Estrogen receptor positive status [ER+]) and V86.1 (Estrogen receptor negative status [ER-]), according to ICD-9 rules.

Also, if you knew the patient was susceptible to endometrial cancer due to her BRCA gene status, you would also report V84.04 (Genetic susceptibility to malignant neoplasm of endometrium) for the complete picture.

ICD-10: Your ICD-10 equivalents include E6601 (Morbid [severe] obesity due to excess calories), Z79.810 (Long term [current] use of selective estrogen receptor modulators [SERMs]), Z17.0 (Estrogen receptor positive status [ER+]), and Z15.04 (Genetic susceptibility tomalignant neoplasm of endometrium).

Bottom line: You cannot say report hyperplasia until the ob-gyn does a biopsy.

Because you have no code to describe this condition, you should report 793.5 (Nonspecific abnormal findings by  ultrasound of genitourinary organs).

Rationale: Endometrial thickening is a finding -- not a diagnosis. Therefore, you should locate the diagnosis code in the signs and symptoms section of ICD-9. If you look under "thickened endometrium," this will lead you to 793.5, Onder says.

Remember, the title for the 793 states, "Nonspecific (abnormal) findings on radiological and other examination of body structure." The fourth digit of "5" indicates the problem is in the genitourinary organs (for which the uterus would qualify). When endometrial thickening is abnormal, that usually means a hormonal imbalance. This commonly occurs during menopause when physician prescribes progesterone therapy.

Think of it this way: An ob-gyn can only see the thickened endometrium on an ultrasound, so this is the logical place to put it. Codes like 793.5 are "beneficial when you end up ordering multiple studies on a patient to come up with a definitive diagnosis," says Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of a practice in Marysville, Ohio.

ICD-10: You'll still see "thickened endometrium" referencing this type of nonspecific (abnormal) finding code. In fact, 793.5's ICD-10 equivalent is R93.8 (Abnormal findings on diagnostic imaging of other specified body structures).