ICD-10 Coding for Adnexal Mass(N83.0, C57.4)
Complete ICD-10-CM coding and documentation guide for Adnexal Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Adnexal Mass
N83.0-N83.9Primary Range
Non-inflammatory disorders of ovary, fallopian tube and broad ligament
This range includes codes for benign and non-inflammatory adnexal masses.
Malignant neoplasms of female genital organs
This range includes codes for malignant adnexal masses.
Unspecified masses and lumps in the abdomen and pelvis
This range is used for unspecified adnexal masses pending further investigation.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N83.0 | Follicular cyst of ovary | Use for benign, simple ovarian cysts confirmed by imaging. |
|
| C57.4 | Malignant neoplasm of other and unspecified female genital organs | Use when malignancy is confirmed by biopsy or imaging suggests high suspicion. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for adnexal mass
Essential facts and insights about Adnexal Mass
Primary ICD-10-CM Codes for adnexal mass
Decision Criteria
clinical Criteria
- Presence of a simple, unilocular cyst on ultrasound.
Applicable To
- Functional ovarian cyst
Excludes
- Malignant ovarian cyst (C56.9)
Clinical Validation Requirements
- Ultrasound showing simple cyst
- No solid components
Code-Specific Risks
- Risk of misclassification if imaging is not clear.
Coding Notes
- Ensure imaging supports the diagnosis of a simple cyst.
C57.4 - Malignant neoplasm of other and unspecified female genital organs
Use when malignancy is confirmed by biopsy or imaging suggests high suspicion.
Applicable To
- Malignant adnexal mass
Excludes
- Benign ovarian cyst (N83.0)
Clinical Validation Requirements
- Elevated CA-125 levels
- O-RADS 4/5 classification on imaging
Coding Notes
Ensure malignancy is confirmed before coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Adnexal Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N83.0.
Impact
Clinical: May lead to incorrect diagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure imaging reports are included in the patient record., Verify documentation completeness before coding.
Impact
Reimbursement: May lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces specificity of health records.
Mitigation Strategy
Always specify laterality if documented.
Impact
High risk of audit if unspecified codes are used without justification.
Mitigation Strategy
Always document and code with the highest specificity available.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Adnexal Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Adnexal Mass
Use these documentation templates to ensure complete and accurate documentation for Adnexal Mass. These templates include all required elements for proper coding and billing.
Benign ovarian cyst
Specialty: GynecologyRequired Elements
- Imaging findings
- Cyst size and characteristics
- Symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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