Inflammatory disease of uterus, except cervix
Chapter 14:Diseases of the genitourinary system
ICD-10 N71 is a billable code used to indicate a diagnosis of inflammatory disease of uterus, except cervix.
N71 refers to inflammatory diseases of the uterus, excluding the cervix, which can encompass a variety of conditions such as salpingitis, oophoritis, pelvic inflammatory disease (PID), endometritis, and cervicitis. These conditions are often interrelated and can result from infections, typically sexually transmitted infections (STIs) like chlamydia and gonorrhea, or from other bacterial infections. Symptoms may include pelvic pain, abnormal vaginal discharge, fever, and dyspareunia. Diagnosis is usually made through clinical evaluation, imaging studies, and laboratory tests. Treatment often involves antibiotics to address the underlying infection, and in some cases, surgical intervention may be necessary to manage complications such as abscess formation. Accurate coding is crucial for proper treatment reimbursement and tracking of disease prevalence.
Detailed patient history, physical examination findings, diagnostic imaging results, and treatment plans.
Diagnosis and management of PID, endometritis, and complications from STIs.
Ensure that all symptoms and treatments are clearly documented to support the diagnosis.
Comprehensive documentation of infection history, laboratory results, and response to treatment.
Management of STIs leading to PID and associated inflammatory diseases.
Focus on the infectious etiology and ensure appropriate coding for any secondary infections.
Used when endometritis is suspected and tissue sampling is needed.
Document indication for biopsy and findings.
Gynecologists should ensure clear documentation of the procedure and its necessity.
Performed for diagnosis and treatment of salpingitis.
Document findings and any interventions performed.
Ensure that the surgical report is detailed and correlates with the diagnosis.
Common causes include sexually transmitted infections, bacterial vaginosis, and post-surgical infections.
Careful documentation of the specific site of inflammation and associated symptoms is crucial for accurate coding.
