Bicornate uterus

This code represents a congenital uterine anomaly where the uterus is heart-shaped, with two distinct horns or cavities and a single cervix and vagina. It results from incomplete fusion of the Müllerian ducts during fetal development. This malformation can impact reproductive health and pregnancy outcomes.

Apply this code when documentation clearly identifies a patient with a bicornate uterus, typically diagnosed via imaging studies such as ultrasound, MRI, or hysterosalpingography (HSG). This diagnosis may be noted during fertility evaluations, recurrent pregnancy loss workups, or routine gynecological examinations.

• Do not confuse with other uterine anomalies like uterus didelphys (two uteri, two cervices) or septate uterus (a single uterus with a septum).
• Code any associated reproductive issues, such as infertility (N97.x) or recurrent pregnancy loss (N96), as secondary diagnoses.
• Ensure the medical record specifies "bicornate" to differentiate from other congenital uterine malformations.