ICD-10 Coding for Bilateral Mastectomy(Z90.13)
Complete ICD-10-CM coding and documentation guide for Bilateral Mastectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Mastectomy
Z90.1-Z90.13Primary Range
Acquired absence of breast and nipple
This range includes codes for the history of mastectomy, specifically Z90.13 for bilateral mastectomy.
Malignant neoplasm of breast
Used when coding for active breast cancer cases requiring mastectomy.
Key Information: ICD-10 code for bilateral mastectomy
Essential facts and insights about Bilateral Mastectomy
Primary ICD-10-CM Code for bilateral mastectomy
Decision Criteria
clinical Criteria
- Patient has undergone bilateral mastectomy with no residual breast tissue.
documentation Criteria
- Operative report specifies bilateral procedure and absence of breast tissue.
Clinical Validation Requirements
- Pathology report confirming absence of breast tissue
- Surgical notes indicating bilateral procedure
Code-Specific Risks
- Incorrectly coding unilateral mastectomy as bilateral
Coding Notes
- Ensure documentation clearly states 'bilateral mastectomy' and includes dates of procedures.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Malignant neoplasm of breast
C50.xxxDifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Mastectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.13.
Impact
Clinical: Misrepresentation of procedure scope, Regulatory: Potential audit issues, Financial: Reduced reimbursement
Mitigation Strategy
Review billing guidelines for modifier usage, Ensure documentation supports bilateral procedure
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate patient records.
Mitigation Strategy
Always use Z90.13 for bilateral mastectomy history.
Impact
Incorrect use of modifiers can trigger audits.
Mitigation Strategy
Verify payer-specific guidelines for modifier usage.
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 Bilateral Mastectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Mastectomy
Use these documentation templates to ensure complete and accurate documentation for Bilateral Mastectomy. These templates include all required elements for proper coding and billing.
Bilateral mastectomy with immediate reconstruction
Specialty: Surgical OncologyRequired Elements
- Procedure type
- Laterality
- Reconstruction details
- Pathology findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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