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v1.0.0
ICD-10 Guide
ICD-10 CodesN85.2

N85.2

Billable

Hypertrophy of uterus

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N85.2 is a billable code used to indicate a diagnosis of hypertrophy of uterus.

Key Diagnostic Point:

Hypertrophy of the uterus refers to an abnormal enlargement of the uterine muscle, which can occur due to various factors including hormonal imbalances, fibroid growth, or other noninflammatory conditions. This condition is often asymptomatic but can lead to complications such as abnormal uterine bleeding, pelvic pain, or pressure symptoms. The hypertrophy may be diffuse or localized, and it is essential to differentiate it from other uterine disorders such as adenomyosis or uterine fibroids. Diagnosis typically involves imaging studies such as ultrasound or MRI, and a thorough clinical evaluation is necessary to rule out malignancy or other serious conditions. Treatment options may vary from observation to surgical intervention, depending on the severity of symptoms and the underlying cause. Understanding the nuances of hypertrophy is crucial for accurate coding and management of related conditions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between hypertrophy and other uterine disorders.
  • Need for comprehensive documentation of symptoms and imaging results.
  • Potential overlap with codes for uterine fibroids and adenomyosis.
  • Variability in clinical presentation and treatment options.

Audit Risk Factors

  • Inadequate documentation of symptoms leading to misdiagnosis.
  • Failure to document imaging studies that support the diagnosis.
  • Incorrect coding due to confusion with similar codes.
  • Lack of follow-up documentation for treatment outcomes.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed clinical notes, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with abnormal uterine bleeding or pelvic pain.

Billing Considerations

Ensure that all relevant symptoms and diagnostic tests are documented to support the diagnosis.

Radiology

Documentation Requirements

Clear imaging reports indicating the presence and extent of hypertrophy.

Common Clinical Scenarios

Ultrasound or MRI findings suggestive of uterine hypertrophy.

Billing Considerations

Radiologists should provide detailed descriptions of findings to aid in accurate coding.

Coding Guidelines

Inclusion Criteria

Use N85.2 When
  • According to ICD
  • 10 guidelines, N85
  • 2 should be used when hypertrophy is confirmed through clinical evaluation and imaging
  • It is important to document the absence of inflammatory conditions and to specify any related symptoms

Exclusion Criteria

Do NOT use N85.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed for symptomatic hypertrophy or related conditions.

Documentation Requirements

Operative report detailing indications for surgery.

Specialty Considerations

Obstetricians should ensure that the reason for surgery aligns with the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of uterine conditions, including hypertrophy. This specificity aids in better tracking of patient outcomes and treatment efficacy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of uterine conditions, including hypertrophy. This specificity aids in better tracking of patient outcomes and treatment efficacy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of uterine conditions, including hypertrophy. This specificity aids in better tracking of patient outcomes and treatment efficacy.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms of uterine hypertrophy?

Common symptoms include abnormal uterine bleeding, pelvic pain, and pressure symptoms. However, many patients may be asymptomatic.

How is uterine hypertrophy diagnosed?

Diagnosis typically involves a combination of clinical evaluation, imaging studies such as ultrasound or MRI, and a thorough review of the patient's medical history.