2025 ICD-10-CM code N71

Inflammation of the uterus, excluding the cervix.

Use additional code(s) to identify the infectious agent if known (B95-B97). Do not use this code for infection of the uterus following delivery (O85, O86.-) or hyperplastic endometritis (N85.0-).

Medical necessity for the diagnosis and treatment of inflammatory disease of the uterus is established by the presence of clinical signs and symptoms, supported by appropriate diagnostic testing. The documentation should clearly demonstrate the severity and impact of the condition on the patient's health.

Diagnosis and treatment of the uterine inflammation are the responsibility of the physician, including identifying any underlying cause and managing related symptoms.

In simple words: Inflammation of the womb (uterus) but not the cervix (neck of the womb).

Inflammatory disease of uterus, except cervix. Includes: endo(myo)metritis, metritis, myometritis, pyometra, uterine abscess. Use additional code (B95-B97) to identify infectious agent.

Example 1: A 35-year-old woman presents with lower abdominal pain, fever, and abnormal vaginal discharge. After examination and testing, she is diagnosed with endometritis (inflammation of the uterine lining) and treated with antibiotics., A patient with a retained intrauterine device (IUD) develops pelvic pain and fever. Imaging reveals pyometra (pus accumulation in the uterus), requiring IUD removal and antibiotic treatment., Following a miscarriage, a woman experiences persistent lower abdominal pain and fever. She is diagnosed with post-abortal metritis and receives appropriate medical care.

Documentation should include signs and symptoms, physical exam findings, laboratory results (e.g., cultures, blood tests), imaging studies (if performed), and details of treatment provided.

** Excludes1: inflammatory diseases of female pelvic organs complicating: abortion or ectopic or molar pregnancy (O00-O07, O08.0), pregnancy, childbirth and the puerperium (O23.-, O75.3, O85, O86.-)

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