ICD-10 Coding for Endometrial Mass(C54.1, C79.82)
Complete ICD-10-CM coding and documentation guide for Endometrial Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Endometrial Mass
C54-C55Primary Range
Malignant neoplasms of corpus uteri
This range includes codes for malignant neoplasms of the endometrium, which are relevant for coding endometrial masses when malignancy is confirmed.
Other noninflammatory disorders of uterus, except cervix
This range includes codes for benign conditions such as endometrial polyps, which may be considered in differential diagnosis.
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 a biopsy confirms a primary malignant neoplasm of the endometrium. |
|
| C79.82 | Secondary malignant neoplasm of genital organs | Use when the endometrial mass is secondary to another primary cancer. |
|
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 endometrial mass
Essential facts and insights about Endometrial Mass
Primary ICD-10-CM Codes for endometrial mass
Decision Criteria
clinical Criteria
- Biopsy confirms malignant neoplasm
documentation Criteria
- Documented histology type and invasion depth
Applicable To
- Endometrioid adenocarcinoma
- Serous carcinoma
Excludes
- Benign endometrial lesions
- Endometriosis
Clinical Validation Requirements
- Biopsy confirming malignancy
- Imaging showing myometrial invasion
Code-Specific Risks
- Misclassification if histology is not documented
- Incorrect use if metastasis is present
Coding Notes
- Ensure histological confirmation of malignancy before using this code.
C79.82 - Secondary malignant neoplasm of genital organs
Use when the endometrial mass is secondary to another primary cancer.
Applicable To
- Metastatic cancer to genital organs
Excludes
- Primary genital organ cancers
Clinical Validation Requirements
- Histological confirmation of metastatic origin
- Primary cancer site documentation
Coding Notes
Ensure primary cancer site is documented and coded.
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 Endometrial Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C54.1.
Impact
Clinical: May delay appropriate treatment., Regulatory: Increases risk of coding audits., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure detailed biopsy reports, Document specific histology
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audits and denials., Data Quality: Affects accuracy of cancer registry data.
Mitigation Strategy
Ensure histology and malignancy are documented to use specific codes like C54.1.
Impact
Lack of detailed histology can lead to incorrect coding.
Mitigation Strategy
Require biopsy confirmation before coding.
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 Endometrial Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Endometrial Mass
Use these documentation templates to ensure complete and accurate documentation for Endometrial Mass. These templates include all required elements for proper coding and billing.
Postmenopausal bleeding with confirmed malignancy
Specialty: GynecologyRequired Elements
- Patient history
- Imaging findings
- Biopsy results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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