2025 ICD-10-CM code N88.9
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the genitourinary system - Noninflammatory disorders of female genital tract (N80-N98) Diseases of the genitourinary system (N00-N99) Feed
Noninflammatory disorder of the cervix uteri, unspecified.
Medical necessity for coding N88.9 is established through the physician's documentation supporting the clinical finding of a noninflammatory cervical disorder. This documentation must clearly justify the need for the evaluation and diagnostic testing used.
The clinical responsibility for this code falls upon the physician or healthcare provider who performs the examination and diagnosis of the cervical condition.This typically involves a thorough gynecological examination, potentially including colposcopy or other diagnostic tests, to rule out infection, malignancy, or other specific pathologies.
- Diseases of the genitourinary system (N00-N99)
- N80-N98 (Noninflammatory disorders of female genital tract)
In simple words: This code describes a problem with the cervix (the lower part of the uterus) that is not caused by infection. The exact nature of the problem isn't specified.
This ICD-10-CM code signifies a non-inflammatory condition affecting the cervix uteri without further specification.It encompasses various non-infectious cervical pathologies not otherwise classified, excluding inflammatory processes, polyps, or other specified conditions.Accurate coding necessitates detailed clinical documentation to support the diagnosis.
Example 1: A 35-year-old female presents with abnormal cervical findings during a routine Pap smear.Colposcopy reveals no evidence of inflammation or malignancy, but there are minor structural abnormalities not meeting the criteria for more specific codes.Code N88.9 is used., A 40-year-old female undergoes a routine pelvic exam.The physician notes subtle changes in the cervical tissue but cannot determine a specific diagnosis without further investigation. The case is coded as N88.9 pending further evaluation., A 28-year-old female presents with post-coital bleeding.After examination and tests that rule out infections and malignancies, and with no clear etiology for the bleeding, the physician uses code N88.9 for billing purposes.
Complete clinical notes describing the examination, any diagnostic procedures performed (e.g., Pap smear, colposcopy, biopsy), and a clear statement indicating the absence of inflammation or other specific diagnoses are essential for proper coding.Imaging reports (if obtained) should also be included in the patient's record.
** This code should be used cautiously, only when all other more specific codes are excluded.The absence of any inflammatory process or other definitive findings must be explicitly documented to support this diagnosis.
- Payment Status: Active
- Specialties:Gynecology, Obstetrics
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center