Pathology/Lab Coding Alert

Question: Our pathologist examined an "endometrial specimen" and assigned a diagnosis of "cystic endometrial hyperplasia." How should we code the case?

New Jersey Subscriber

Answer: The correct code for the biopsy exam is 88305 (Level IV -- Surgical pathology, gross and microscopic examination ... Endometrium, curettings/biopsy ...). This code describes an endometrial biopsy, not a complete uterine specimen that might have the same diagnosis.

You should assign the diagnosis as N85.00 (Endometrial hyperplasia, unspecified). If you look up the category N85.0 (Endometrial hyperplasia) and explore the code choices, you can see that the note under N85.00 includes "Hyperplasia (adenomatous) (cystic) (glandular) of endometrium, Hyperplastic endometritis." The term "cystic" should direct you to this code.

In contrast, N85.01 (Endometrial hyperplasia) describes hyperplasia without atypical cells, classified as complex or simple, which indicate specific gland patterns that your pathologist did not note in this case. You should reserve N85.02 (Endometrial intraepithelial neoplasia [EIN]) for cases when the pathologist notes cellular atypia, such as enlarged epithelia cells with reduced cytoplasm relative to nuclear material.