The physician uses the same procedure code for a uterine fibroid or polyp specimen, so can a wrong diagnosis cost your pathologist pay? Certainly, say the experts. Read on to know how.
Find Your Diagnosis Codes
“Uterine fibroids and polyps are similar because they’re both growths, but they’re from different source tissue, and ICD-9 categorizes them to completely different codes,” says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.
Uterine Polyps: An overgrowth of the endometrial lining, polyps usually occur within the uterine cavity and are typically malleable and small. Uterine polyps are often superficial, and therefore easy to remove.
ICD-9 distinguishes uterine polyps based on location and pathology, as follows:
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- 621.0—Polyp of corpus uteri. The pathology report might list this finding as an endometrial polyp or a uterine polyp. This code refers only to intracavitary polyps: it excludes polyps removed from the cervix. You should report cervical polyps with the following code:
- 622.7—Mucous polyp of cervix. This code includes any cervical polyp not otherwise specified, but excludes adenomatous cervical polyps. You should report this neoplastic cervical polyp with the following code:
- 219.0—Other benign neoplasm of cervix uteri. Use for adenomatous cervical polyps.
Uterine Fibroids: Fibroids are outgrowths of the smooth muscle of the uterine wall, and they may be much larger, tough, and “embedded” in the thick muscular layer of the uterus. You might also see fibroid called “leiomyoma,” “myoma,” “fibromyoma,” or “leiomyofibroma.”
“ICD-9 distinguishes fibroids based on the location within the uterine wall,” Witt says.
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