Radiology 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: When the diagnosis code system changes to ICD-10, 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 crosswalked ICD-10 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 or an ICD-10 code, checking the index and tabular listing for accuracy of the description is always important.