When you get a pathology report with a hyperplasia diagnosis, you have five possible ICD-9 codes to report.
But your options are going to change in ICD-10, when you’ll only have three options.
Hyperplasia defined: When hyperplasia occurs, this means the patient has an increase in the number of cells. In the case of endometrial hyperplasia, this means the cells have proliferated in the endometrium, or the inner lining of the uterus.
An endometrial intraepithelial neoplasm is a precancerous lesion in the endometrium that makes the uterine lining more susceptible to endometroid endometrial adenocarcinoma.
621.30, Endometrial hyperplasia, unspecified
621.31, Simple endometrial hyperplasia without atypia
621.32, Complex endometrial hyperplasia without atypia
621.33, Endometrial hyperplasia with atypia
621.35, Endometrial intraepithelial neoplasia [EIN]
N85.00, Endometrial hyperplasia, unspecified
N85.01, Benign endometrial hyperplasia
N85.02, Endometrial intraepithelial neoplasm [EIN]
ICD-10 Change: In the case of 621.30 and 621.31, you have a one-to-one relationship between your ICD-9 and ICD-10 codes (N85.00 and N85.01 respectively). However, ICD-10 rolls 621.32, 621.33, and 621.35 into N85.02.
Documentation: Other terms for N85.00 include “hyperplasia (adenomatous) (cystic) (glandular) of endometrium” and “hyperplastic endometritis.” A note listed underneath N85.01 includes “endometrial hyperplasia (complex) (simple) without atypia.” Additionally, another note underneath N85.02 is “endometrial hyperplasia with atypia.”
You’ll find these codes in the Alphabetic Index as follows:
Atypical, atypism — see also condition
- endometrium N85.9
- hyperplasia N85.00
Endometritis (decidual) (nonspecific) (purulent) (senile) (atrophic) (suppurative) N71.9
– hyperplastic (see also Hyperplasia, endometrial) N85.00
- endometrium, endometrial (adenomatous) (benign) (cystic) (glandular) (glandular-cystic) (polypoid) N85.00
- with atypia N85.02
- cervix — see Dysplasia, cervix
- complex (without atypia) N85.01
- simple (without atypia) N85.01
- glandularis cystica uteri (interstitialis) (see also Hyperplasia, endometrial) N85
- uterus, uterine N85.2
- endometrium (glandular) (see also Hyperplasia, endometrial) N85.00
– endometrium (glandular) (see also Hyperplasia, endometrial) N85.00
Watch out: Suppose the provider suspects hyperplasia. He detects and documents “endometrial thickening” during an ultrasound examination. What diagnosis should you report? Just because the provider documents endometrial thickening does not mean the patient has endometrial hyperplasia. Many coders make this mistake. You should not code this as hyperplasia because physicians don’t always consider the thickening of the uterus “abnormal;” in fact, it’s just a monthly “ramp up” for all women. For ICD10, this condition has been referenced to R93.8 (Abnormal findings on diagnostic imaging of other specified body structures). You will find this in the index by looking up the term “thickening, endometrium.”
Coder Tips: Do not report hyperplasia until the provider has performed a biopsy, and you have a pathology report that confirms this condition.
You have an Excludes1 note underneath the N85.– category, you’ll see an Excludes1 note that forbids you from reporting these codes with endometriosis (N80.-), inflammatory diseases of uterus (N71-), noninflammatory disorders of cervix, except malposition (N86-N88), polyp of corpus uteri (N84.0), and uterine prolapse (N81-).
You’ll also find another Excludes1 note underneath N85.02 forbidding you from reporting this code with malignant neoplasm of endometrium (with endometrial intraepithelial neoplasia [EIN]) (C54.1).