ICD-10 Coding for Carcinoma of the Uterus(C54.1, C54.2)
Complete ICD-10-CM coding and documentation guide for Carcinoma of the Uterus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Carcinoma of the Uterus
C54-C55Primary Range
Malignant neoplasms of corpus uteri and uterus, part unspecified
This range includes all malignant neoplasms of the uterus, specifically focusing on the corpus uteri and isthmus.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C54.1 | Malignant neoplasm of endometrium | Use when carcinoma is confined to the endometrium of the corpus uteri. |
|
| C54.2 | Malignant neoplasm of myometrium | Use when carcinoma involves the uterine isthmus. |
|
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 carcinoma uterus
Essential facts and insights about Carcinoma of the Uterus
Primary ICD-10-CM Codes for carcinoma uterus
Decision Criteria
clinical Criteria
- Histological confirmation of endometrial carcinoma
documentation Criteria
- Documented depth of myometrial invasion
Applicable To
- Endometrial carcinoma
Excludes
- Malignant neoplasm of cervix uteri (C53.-)
Clinical Validation Requirements
- Histological confirmation of endometrioid adenocarcinoma
- Documented depth of myometrial invasion
Code-Specific Risks
- Misclassification if depth of invasion is not documented
Coding Notes
- Ensure histology and depth of invasion are clearly documented.
C54.2 - Malignant neoplasm of myometrium
Use when carcinoma involves the uterine isthmus.
Applicable To
- Carcinoma involving uterine isthmus
Excludes
- Malignant neoplasm of cervix uteri (C53.-)
Clinical Validation Requirements
- Histological confirmation of adenocarcinoma involving the isthmus
Coding Notes
Ensure site of involvement is clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.6Differential 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 Carcinoma of the Uterus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C54.1.
Impact
Clinical: Impacts treatment decisions and prognosis., Regulatory: Non-compliance with coding guidelines., Financial: May affect reimbursement rates.
Mitigation Strategy
Ensure pathology reports include depth of invasion., Cross-check clinical notes for completeness.
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Non-compliance with specificity requirements., Data Quality: Decreases accuracy of health data.
Mitigation Strategy
Use C54.1 or C54.2 based on documented site.
Impact
Inadequate documentation of histologic subtype and grade.
Mitigation Strategy
Implement standardized pathology reporting templates.
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 Carcinoma of the Uterus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Carcinoma of the Uterus
Use these documentation templates to ensure complete and accurate documentation for Carcinoma of the Uterus. These templates include all required elements for proper coding and billing.
Endometrial carcinoma diagnosis
Specialty: Gynecologic OncologyRequired Elements
- Histologic type
- Grade
- Depth of myometrial invasion
- Lymphovascular space invasion
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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