Oncology & Hematology Coding Alert

Question: I’m coding an ultrasound note. What diagnosis code should I report for fluid in the endometrial cavity?

Montana Subscriber

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

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

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