Ob-Gyn Coding Alert

Question: The ob-gyn performs hysteroscopy with dilation and curettage (D&C). The pathology report states that the ob-gyn found no endometrial polyp or endometrial glandular hyperplasia, neither atypia nor malignant tumor in the mid-secretory endometrium of the patient. Instead, she notes it as a "redundant tissue." What code best describes the diagnosis?

New York Subscriber

Answer: The path report is telling you all was normal, and you won't find any ICD-9 code for this result. You should instead code the reason for the procedure.

Before assigning the typical reason for the procedure ��" 793.5 (Nonspecific abnormal findings on radiological and other examination of body structure; genitourinary organs), discuss the code with your ob-gyn.

Rationale: You have indicated that the patient has redundant tissue, which usually refers to endometrial thickening of the tissue lining the uterus. This finding is often the result of discovery during an ultrasound examination, and it most certainly needs to be further evaluated. In this case your physician elected to perform the hysteroscopy with D&C (58558, Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).

ICD-10: If you plug this code into the American Academy of Professional Coders (AAPC)'s ICD-9 to ICD-10 conversion (URL: http://www.aapc.com/ICD-10/codes/index.aspx), you'll see 793.5 will become R93.4 (Abnormal findings on diagnostic imaging of urinary organs). This ICD-9 assigned conversion does not apply in this case since the abnormal finding is not of a urinary organ. Therefore, the more appropriate converted code would be R93.8 (Abnormal findings on diagnostic imaging of other specified body structures).