Pathology/Lab Coding Alert

Question: I've been coding endometrial hyperplasia as N85.0, but a coder friend tells me that this is not correct. If N85.0 is wrong, how should I code it?

California Subscriber

Answer: Your friend is technically correct, but you're not far off. The problem is that N85.0 (Endometrial hyperplasia) is a truncated code. You're required to report the code to the 5th digit using one of the following codes:

• N85.00 (Endometrial hyperplasia, unspecified)
• N85.01 (Benign endometrial hyperplasia)
• N85.02 (Endometrial intraepithelial neoplasm (EIN)).

Without any indicators beyond "endometrial hyperplasia," you'd need to select N85.00.

However, the pathology report typically provides greater granularity and will give you some indicator for choosing either N85.01 or N85.02.

Here are some additional words to watch for describing endometrial hyperplasia, which will help you choose the proper code:

• N85.00

            o Adenomatous
            o Benign
            o Cystic
            o Glandular
            o Glandular-cystic
            o Polypoid
            o Hyperplastic endometritis

• N85.01

            o Without atypia
            o Complex without atypia
            o Simple without atypia

• N85.02

            o EIN
            o With atypia