Inflammatory disease of uterus, unspecified
ICD-10 N71.9 is a billable code used to indicate a diagnosis of inflammatory disease of uterus, unspecified.
Inflammatory disease of the uterus encompasses a range of conditions affecting the female reproductive system, primarily involving the uterus, fallopian tubes, and ovaries. This code is used when the specific type of inflammatory disease is not specified. Common conditions associated with this code include salpingitis (inflammation of the fallopian tubes), oophoritis (inflammation of the ovaries), pelvic inflammatory disease (PID), endometritis (inflammation of the endometrium), and cervicitis (inflammation of the cervix). Symptoms may include pelvic pain, abnormal vaginal discharge, fever, and dyspareunia. Diagnosis typically involves a combination of clinical evaluation, imaging studies, and laboratory tests. Treatment often includes antibiotics to address the underlying infection, and in some cases, surgical intervention may be necessary. Accurate coding is crucial for appropriate treatment and reimbursement, as well as for tracking the incidence of these conditions in the population.
Detailed clinical notes including symptoms, diagnostic tests, and treatment plans.
Patients presenting with pelvic pain, abnormal discharge, or fever.
Ensure that all relevant tests and treatments are documented to support the diagnosis.
Comprehensive history of infections, treatment responses, and follow-up care.
Patients with recurrent PID or those requiring long-term antibiotic therapy.
Documenting the rationale for antibiotic choice and any resistance patterns.
Used when endometrial inflammation is suspected.
Document indication for biopsy and findings.
Gynecologists should ensure proper consent and follow-up.
Performed for suspected PID or other inflammatory conditions.
Document findings and any interventions performed.
Ensure that the surgical report is detailed.
Document the patient's symptoms, diagnostic tests performed, and treatment plans. Ensure that the physician's notes specify the nature of the inflammatory disease, even if it is unspecified.
