Benign endometrial hyperplasia
ICD-10 N85.01 is a billable code used to indicate a diagnosis of benign endometrial hyperplasia.
Benign endometrial hyperplasia is a condition characterized by the abnormal proliferation of the endometrial lining of the uterus. This hyperplastic change is often a response to prolonged estrogen stimulation without adequate progesterone opposition, leading to thickening of the endometrium. Clinically, patients may present with symptoms such as abnormal uterine bleeding, which can range from heavy menstrual periods (menorrhagia) to intermenstrual bleeding. The condition is typically diagnosed through a combination of clinical evaluation, imaging studies such as transvaginal ultrasound, and histological examination via endometrial biopsy. While benign, endometrial hyperplasia can be classified into simple and complex types, with the latter having a higher risk of progression to endometrial carcinoma if left untreated. Management often involves hormonal therapy, such as progestins, to counteract the effects of estrogen and promote the shedding of the hyperplastic endometrium. Regular follow-up and monitoring are essential to prevent potential complications.
Detailed patient history, including menstrual cycle patterns, symptoms, and any previous gynecological conditions.
Patients presenting with abnormal uterine bleeding, postmenopausal bleeding, or findings on imaging suggestive of hyperplasia.
Ensure that the type of hyperplasia is clearly documented, along with any treatment plans and follow-up recommendations.
Histopathological reports detailing the findings of endometrial biopsies.
Evaluation of endometrial tissue samples for hyperplasia or malignancy.
Accurate coding based on biopsy results is crucial for appropriate management and follow-up.
Used when a patient with suspected hyperplasia undergoes a D&C for diagnosis.
Document indication for procedure, findings, and any follow-up plans.
Obstetricians should ensure that the procedure is justified based on clinical findings.
Simple hyperplasia involves an increase in the number of endometrial glands without atypia, while complex hyperplasia has a more intricate glandular architecture and may have atypical cells, which increases the risk of progression to cancer.
