ICD-10 Coding for Cervical Intraepithelial Neoplasia Grade 3(D06.9)
Complete ICD-10-CM coding and documentation guide for Cervical Intraepithelial Neoplasia Grade 3. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Intraepithelial Neoplasia Grade 3
Key Information: ICD-10 code for CIN III
Essential facts and insights about Cervical Intraepithelial Neoplasia Grade 3
Primary ICD-10-CM Code for cervical intraepithelial neoplasia grade 3
Decision Criteria
clinical Criteria
- Biopsy confirms CIN III with p16 positivity.
documentation Criteria
- Pathology report explicitly states CIN III.
Applicable To
- CIN III
- HSIL with CIN III
- Severe dysplasia
Clinical Validation Requirements
- Histology showing full-thickness involvement
- p16 block-positive
- HPV 16/18 positive
Code-Specific Risks
- Incorrectly coding CIN II as CIN III without p16 confirmation
Coding Notes
- Ensure documentation specifies CIN III or HSIL with CIN III.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Moderate cervical dysplasia
N87.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Intraepithelial Neoplasia Grade 3 to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D06.9.
Impact
Clinical: Misclassification of dysplasia severity., Regulatory: Potential audit findings., Financial: Incorrect reimbursement due to coding errors.
Mitigation Strategy
Require p16 testing for CIN 2-3, Educate providers on documentation standards
Impact
Reimbursement: Incorrect DRG assignment may affect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Verify p16 status; if negative, code as CIN II.
Impact
Risk of incorrect coding for CIN 2-3 cases.
Mitigation Strategy
Implement mandatory p16 testing for CIN 2-3.
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 Cervical Intraepithelial Neoplasia Grade 3, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Intraepithelial Neoplasia Grade 3
Use these documentation templates to ensure complete and accurate documentation for Cervical Intraepithelial Neoplasia Grade 3. These templates include all required elements for proper coding and billing.
CIN III confirmed by biopsy
Specialty: GynecologyRequired Elements
- Histology findings
- p16 status
- HPV typing
- Margin status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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