Acute inflammatory disease of uterus
ICD-10 N71.0 is a billable code used to indicate a diagnosis of acute inflammatory disease of uterus.
Acute inflammatory disease of the uterus encompasses a range of conditions characterized by inflammation of the female reproductive organs, primarily affecting the uterus, fallopian tubes, and ovaries. This condition often arises from infections, most commonly sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoeae, leading to pelvic inflammatory disease (PID). Symptoms may include pelvic pain, fever, abnormal vaginal discharge, and dyspareunia. Salpingitis (inflammation of the fallopian tubes) and oophoritis (inflammation of the ovaries) are common manifestations. Endometritis, the inflammation of the endometrium, can occur postpartum or post-abortion. Cervicitis, inflammation of the cervix, may also be present. Diagnosis typically involves a combination of clinical evaluation, laboratory tests, and imaging studies. Treatment often includes broad-spectrum antibiotics to cover potential pathogens, and in severe cases, surgical intervention may be necessary. Accurate coding requires thorough documentation of the clinical findings, treatment provided, and any associated procedures.
Detailed clinical notes on symptoms, diagnostic tests, and treatment plans.
Patients presenting with pelvic pain, fever, and abnormal discharge.
Ensure documentation reflects the acute nature of the condition and any surgical interventions performed.
Thorough history of STIs, laboratory results, and treatment regimens.
Management of PID with antibiotic therapy and monitoring for complications.
Documenting the response to treatment and any follow-up care is crucial.
Used in cases of acute endometritis requiring surgical intervention.
Document indication for procedure, findings, and post-operative care.
Gynecologists should ensure clear linkage between diagnosis and procedure.
Performed for severe salpingitis with abscess formation.
Document the need for surgery and findings during the procedure.
Ensure that the acute nature of the condition is well-documented.
Common symptoms include pelvic pain, fever, abnormal vaginal discharge, and dyspareunia. These symptoms may vary based on the specific inflammatory condition present.
Treatment typically involves broad-spectrum antibiotics to address the underlying infection. In severe cases, surgical intervention may be necessary.
Documentation should include clinical findings, diagnostic tests, treatment plans, and any associated procedures to support the coding of N71.0.
