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2025 ICD-10-CM code N84.9

Polyp of female genital tract, unspecified.

This code should be used only when the location of the polyp is unspecified or unknown.More specific codes should be used if the location can be determined.

Modifiers may be applicable depending on the specific circumstances of the encounter and procedures performed (e.g., location of service, type of procedure).

Medical necessity is established based on the clinical presentation (e.g., abnormal bleeding, symptoms related to the presence of a polyp), the findings of the physical examination and diagnostic imaging, and the need for further investigation or treatment.

The clinical responsibility involves the physician conducting a thorough examination, possibly including imaging studies (e.g., ultrasound, colposcopy), to determine the location and nature of the polyp.If indicated, surgical removal and pathological evaluation may be necessary.

IMPORTANT:N84.0 (Polyp of corpus uteri), N84.1 (Polyp of cervix uteri), N84.2 (Polyp of vagina), N84.3 (Polyp of vulva), N84.8 (Polyp of other parts of female genital tract)are more specific codes that should be used if the location of the polyp is known.This code should only be used when the exact location is undetermined.

In simple words: This code means a doctor found a small, abnormal growth somewhere in a woman's reproductive organs, but they don't know exactly where it is yet.

This code represents a polyp found in the female genital tract, where the specific location is unknown or not specified.It includes benign growths that protrude from the mucosal surface.Further investigation may be necessary to determine the exact location and nature of the polyp.

Example 1: A 45-year-old female patient presents with abnormal uterine bleeding.A transvaginal ultrasound reveals a polyp in the female genital tract, but the precise location is uncertain.N84.9 is used for billing purposes., During a routine gynecological exam, a small polyp is discovered during a visual inspection of the cervix. The location cannot be precisely determined. The physician documents the finding, however, additional testing is required to determine the exact location. N84.9 is recorded pending additional information., A postmenopausal woman experiences vaginal bleeding.An examination and imaging show a polyp within the female genital tract, but its precise location (uterus, cervix, vagina) remains unclear due to technical limitations. N84.9 is used to reflect the diagnostic uncertainty.

Complete medical history, physical examination findings, results of diagnostic imaging (e.g., ultrasound, MRI), pathology report if polyp is removed.

** Further investigation is usually necessary to determine the precise location and nature (benign or malignant) of the polyp.The appropriate level of diagnostic and therapeutic intervention depends on the clinical context and the patient's symptoms.

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