ICD-10 Coding for History of Uterine Cancer(Z85.42)
Complete ICD-10-CM coding and documentation guide for History of Uterine Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Uterine Cancer
Z85.42Primary Range
Personal history of malignant neoplasm of other parts of uterus
This code is used to document a patient's history of uterine cancer when the cancer is no longer active and treatment has concluded.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Used for surveillance visits following completed cancer treatment.
Key Information: ICD-10 code for history of uterine cancer
Essential facts and insights about History of Uterine Cancer
Primary ICD-10-CM Code for history of uterine cancer
Decision Criteria
clinical Criteria
- No active treatment and imaging confirms no residual disease
documentation Criteria
- Explicit statement of 'history of' in medical records
Applicable To
- History of endometrial cancer
- History of uterine corpus cancer
Clinical Validation Requirements
- Pathology report confirming prior malignancy
- Imaging showing no residual disease
- No ongoing treatment
Code-Specific Risks
- Incorrectly coding active cancer as history
- Confusing with history of cervical cancer
Coding Notes
- Ensure documentation clearly states 'history of' and confirms no active treatment.
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 Uterine Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.42.
Impact
Clinical: Potential mismanagement of patient care., Regulatory: Non-compliance with coding standards., Financial: Risk of claim denials or audits.
Mitigation Strategy
Use specific cancer history templates., Verify treatment completion and current status.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Misrepresentation of patient's clinical status., Data Quality: Inaccurate health records affecting patient care.
Mitigation Strategy
Use C54.1 for active cancer cases.
Impact
Using history codes for active cancer cases.
Mitigation Strategy
Regular training on code differentiation and documentation requirements.
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 Uterine Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Uterine Cancer
Use these documentation templates to ensure complete and accurate documentation for History of Uterine Cancer. These templates include all required elements for proper coding and billing.
Annual Surveillance Visit
Specialty: GynecologyRequired Elements
- Patient history
- Treatment completion date
- Current status
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for History of Uterine Cancer? Ask your questions below.