Radiology Coding Alert

Question: The radiologist documented their CT scan findings as, “There is note made of a 4.1-cm thin-walled simple appearing cyst present within the right-sided pelvis in the region of the right external iliac nodal group that appears separate from the right ovary.” I was thinking of using N94.89 because the index shows “Cyst-Pelvis-Female”, but the provider didn’t agree because the diagnosis mentions “female genital organs” and this is separate from the ovary. I’m also thinking I should use R19.07 to reflect the pelvic mass.

Could you please indicate which ICD-10-CM code(s) I should use to document the report?

Codify Subscriber

Answer: While R19.07 (Generalized intra-abdominal and pelvic swelling, mass and lump) is a good guess, you should use R19.03 (Right lower quadrant abdominal swelling, mass and lump) since the documentation specifically calls out the right pelvis. If the cyst is in or next to the fallopian tube, fibria, etc., then you should use N94.89 (Other specified conditions associated with female genital organs and menstrual cycle). To ensure you’re coding the report accurately, you should double-check the documentation or consult the radiologist to clarify where the cyst is located.

Additionally, if the cyst were presenting in the ovary, the N83.- (Noninflammatory disorders of ovary, fallopian tube and broad ligament) group of codes covers a wide variety of symptoms presenting in the ovaries.