2025 ICD-10-CM code N85.01
Benign endometrial hyperplasia.Endometrial hyperplasia without atypia.
Medical necessity for the diagnosis and treatment of benign endometrial hyperplasia is based on the patient's symptoms, the risk of progression to endometrial cancer, and the impact on the patient's quality of life.
Diagnosis and management of benign endometrial hyperplasia typically falls under the purview of gynecologists or obstetrician-gynecologists. They are responsible for evaluating patients, performing diagnostic procedures like endometrial biopsy or hysteroscopy, and recommending appropriate treatment strategies.
In simple words: This code refers to a non-cancerous condition where the lining of the uterus becomes thicker than normal.
Benign endometrial hyperplasia, also known as simple or complex endometrial hyperplasia without atypia. This condition involves the overgrowth of the uterine lining (endometrium) but does not show precancerous changes (atypia).
Example 1: A 45-year-old woman presents with irregular and heavy menstrual bleeding. An endometrial biopsy reveals benign endometrial hyperplasia., A 55-year-old postmenopausal woman experiences unexpected vaginal bleeding. Ultrasound and endometrial sampling confirm a diagnosis of benign endometrial hyperplasia., A 30-year-old woman with polycystic ovary syndrome undergoes an endometrial biopsy which shows benign endometrial hyperplasia.
Documentation should include details of the patient's presenting symptoms, findings from physical examination, results of diagnostic tests (e.g., ultrasound, endometrial biopsy, hysteroscopy), and the physician's assessment of the type and severity of endometrial hyperplasia.
** Excludes1: endometriosis (N80.-), inflammatory diseases of uterus (N71.-), noninflammatory disorders of cervix, except malposition (N86-N88), polyp of corpus uteri (N84.0), uterine prolapse (N81.-)
- Specialties:Gynecology, Obstetrics and Gynecology, Family Medicine
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital