Choosing the Correct Code for Documented Endometriosis
Question: My provider documented “endometriosis with chronic pelvic pain” after performing a diagnostic laparoscopy. The operative report confirms endometriosis involving the uterosacral ligaments, but the assessment does not specify laterality. What diagnosis code should I assign in this situation? California Subscriber Answer: Several ICD-10-CM codes may seem appropriate at first, but only one matches the documentation and ICD-10-CM coding conventions. You might initially consider N80.9 (Endometriosis, unspecified) because the provider did not document laterality, but keep in mind that unspecified codes apply only when the medical record lacks detail about the condition’s site. In this case, the provider clearly documented involvement of the uterosacral ligaments, which rules out N80.9. You may also think about assigning a code from the R10.2- (Pelvic and perineal pain) set because the provider documented chronic pelvic pain, but it is best practice not to report symptom codes when a confirmed diagnosis explains the symptom. Pelvic pain is a symptom of endometriosis and does not qualify as a separately reportable condition in this scenario. Inclusion terms under the N80.3- (Endometriosis of pelvic peritoneum) code set encompass endometriosis of pelvic supporting structures, including the uterosacral ligaments. Since the provider did not document laterality, N80.30 (Endometriosis of pelvic peritoneum, unspecified) accurately reflects the documented diagnosis and anatomic involvement and is the correct code selection. Keep in mind: Laterality does not apply to all endometriosis codes. When a provider documents a specific anatomic site, assign the most specific site-based code available, even when laterality is absent from the record. Reserve unspecified diagnosis codes for situations in which the provider does not identify the site of disease. For future claims: When providers document additional details including laterality, multiple sites of involvement (for example, ovarian and pelvic peritoneal disease), or deep infiltrating endometriosis, review the N80.- code set to determine the most appropriate code. Michelle Falci, BA, M Falci Communications LLC
