ICD-10 Coding for Cervical Mass(R87.619, D06.9, C53.9, N88.8)
Complete ICD-10-CM coding and documentation guide for Cervical Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Mass
R87.61-Primary Range
Abnormal findings in specimens from cervix uteri
Used for unspecified cervical mass or lesion without confirmed histology.
Other specified noninflammatory disorders of cervix uteri
Used for benign cervical polyps confirmed by biopsy.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R87.619 | Unspecified abnormal cytological findings in specimens from cervix uteri | Use when a cervical mass is identified but not yet histologically confirmed. |
|
| D06.9 | Carcinoma in situ of cervix, unspecified | Use when biopsy confirms CIN III or carcinoma in situ. |
|
| C53.9 | Malignant neoplasm of cervix uteri, unspecified | Use when biopsy confirms invasive cervical cancer. |
|
| N88.8 | Other specified noninflammatory disorders of cervix uteri | Use for benign cervical polyps confirmed by biopsy. |
|
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 cervical mass
Essential facts and insights about Cervical Mass
Primary ICD-10-CM Codes for cervical mass
Decision Criteria
clinical Criteria
- Presence of cervical mass without histological confirmation
Applicable To
- Unspecified cervical mass
- Unspecified cervical lesion
Clinical Validation Requirements
- Abnormal Pap smear results
- Colposcopy findings without histological confirmation
Code-Specific Risks
- Misclassification if histology confirms neoplasm
Coding Notes
- Ensure documentation specifies the nature of the mass and any associated symptoms.
D06.9 - Carcinoma in situ of cervix, unspecified
Use when biopsy confirms CIN III or carcinoma in situ.
Applicable To
- CIN III
- Severe dysplasia of cervix
Excludes
- Invasive cervical cancer (C53)
Clinical Validation Requirements
- Biopsy showing CIN III
- p16 positive staining
- High-risk HPV positive
Coding Notes
Ensure biopsy results are documented to support this code.
C53.9 - Malignant neoplasm of cervix uteri, unspecified
Use when biopsy confirms invasive cervical cancer.
Applicable To
- Invasive cervical cancer
Excludes
- Carcinoma in situ (D06)
Clinical Validation Requirements
- Biopsy confirming invasive cancer
- FIGO staging documentation
Coding Notes
Ensure invasive nature is documented and confirmed by biopsy.
N88.8 - Other specified noninflammatory disorders of cervix uteri
Use for benign cervical polyps confirmed by biopsy.
Applicable To
- Benign cervical polyp
Excludes
- Malignant neoplasm (C53)
Clinical Validation Requirements
- Biopsy confirming benign nature
- Physical exam findings
Coding Notes
Ensure benign nature is documented through biopsy.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Right lower quadrant pain
R10.31Differential 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 Cervical Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R87.619.
Impact
Clinical: May affect treatment decisions, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Always document the side of the cervix affected, Use templates to ensure completeness
Impact
Reimbursement: Incorrect coding may lead to denied claims, Compliance: Non-compliance with coding standards, Data Quality: Inaccurate clinical data reporting
Mitigation Strategy
Upgrade to D06 or C53 based on histology
Impact
Risk of coding errors without biopsy confirmation
Mitigation Strategy
Require biopsy results before finalizing codes
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 Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Mass
Use these documentation templates to ensure complete and accurate documentation for Cervical Mass. These templates include all required elements for proper coding and billing.
Cervical Mass Excision
Specialty: GynecologyRequired Elements
- Location of mass
- Size and characteristics
- Procedure details
- Pathology results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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