ICD-10 Coding for History of Hysterectomy(Z90.710, Z90.711)
Complete ICD-10-CM coding and documentation guide for History of Hysterectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Hysterectomy
Z90.71Primary Range
Acquired absence of uterus and cervix
This range includes codes for documenting the history of hysterectomy, specifying whether the cervix is absent or present as a stump.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z90.710 | Acquired absence of both cervix and uterus | Use when both the uterus and cervix have been removed. |
|
| Z90.711 | Acquired absence of uterus with cervical stump | Use when the uterus is removed but the cervix remains as a stump. |
|
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 history of hysterectomy
Essential facts and insights about History of Hysterectomy
Primary ICD-10-CM Codes for history of hysterectomy
Decision Criteria
clinical Criteria
- Confirmation of total hysterectomy with cervix removal
documentation Criteria
- Operative report or imaging confirming absence of cervix
Applicable To
- History of total hysterectomy
Excludes
- Cervical stump present
Clinical Validation Requirements
- Operative report confirming removal of cervix and uterus
- Pelvic imaging showing absence of cervix
Code-Specific Risks
- Incorrectly used when cervix is present
Coding Notes
- Ensure documentation specifies the absence of the cervix.
Z90.711 - Acquired absence of uterus with cervical stump
Use when the uterus is removed but the cervix remains as a stump.
Applicable To
- History of supracervical hysterectomy
Excludes
- Total hysterectomy with cervix removed
Clinical Validation Requirements
- Post-hysterectomy ultrasound identifying cervical stump
Coding Notes
Ensure documentation specifies the presence of a cervical stump.
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.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Hysterectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.710.
Impact
Clinical: Inaccurate patient history, Regulatory: Non-compliance with coding standards, Financial: Potential for claim denials
Mitigation Strategy
Review operative reports, Include cervical status in documentation
Impact
Reimbursement: May lead to incorrect billing and potential denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Verify operative reports or imaging to confirm cervix status.
Impact
Inaccurate documentation of cervical status post-hysterectomy.
Mitigation Strategy
Ensure thorough review of operative and imaging reports.
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 History of Hysterectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Hysterectomy
Use these documentation templates to ensure complete and accurate documentation for History of Hysterectomy. These templates include all required elements for proper coding and billing.
Gynecology Progress Note
Specialty: GynecologyRequired Elements
- Type of hysterectomy
- Date of procedure
- Cervical status
- Oophorectomy status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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