Ob-Gyn Coding Alert

Question: A patient was referred to one of our gynecologists because of fluid in the endometrial cavity. What diagnosis code should I report?

Montana Subscriber

Answer: You should report abnormal finding on ultrasound: 793.5 (Nonspecific [abnormal] findings on radiological and other examination of genitourinary organs).

ICD-10: When your diagnosis system changes, you will report R93.8 (Abnormal findings on diagnostic imaging of other specified body structures).

Caution: Although the ICD-9 to ICD-10 translation tables indicate R93.4 (Abnormal findings on diagnostic imaging of urinary organs) as the ICD-10 code, this would be incorrect. Obviously, the uterus is not a urinary organ. The lesson here is that whether you are dealing with an ICD-9 or an ICD-10 code, checking the tabular listing for accuracy of the description is always important.