Bellevue, NE
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The patient was taken to the operation room where she was placed under general anesthesia without difficulty. A timeout was performed. She was then placed in the dorsal lithotomy position. Exam under anesthesia was performed. Uterus was small and mobile, adnexa normal without masses. The patient was then prepped and draped in a normal sterile fashion. A speculum was then placed in the vagina and the cervix was visualized and normal in appearance. A single toothed tenaculum was then placed on the anterior lip of the cervix. The cervix was then dilated sequentially using Pratt dilators to 5 mm to accommodate the hysteroscope. The hysertoscope was introduced without difficulty finding the fundus. Uterine cavity appeared normal without evidence of polypoid tissue. Both tubal Ostia were visualized. Endometrium was smooth and normal in appearance. Hysteroscope was removed, deficit of 490ml. The tenaculum was then removed from the cervix with excellent hemostasis noted at the tenaculum sites. The speculum was then removed.

If the patient was scheduled for a polypectomy and nothing was found abnormal, and the MD performed ONLY a diagnostic hysteroscopy, what would my ICD 10 be since there was NO polyp found?

Thank you!


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The Z01 codes are preventive dx codes and I would not use with a hysteroscopy. If nothing is found, you would use the indication for the scope as the dx, which was the polyp .