ICD-10 Coding for Hysterectomy Status(Z90.710, Z90.711)
Complete ICD-10-CM coding and documentation guide for Hysterectomy Status. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hysterectomy Status
Z90.71-Z90.79Primary Range
Acquired absence of organs, not elsewhere classified
This range includes codes for the acquired absence of the uterus and cervix, which are relevant for documenting hysterectomy status.
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 cervix and uterus have been surgically removed. |
|
| Z90.711 | Acquired absence of uterus with remaining cervical stump | Use when the uterus is removed but the cervix remains. |
|
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 hysterectomy status
Essential facts and insights about Hysterectomy Status
Primary ICD-10-CM Codes for hysterectomy status
Decision Criteria
clinical Criteria
- Both cervix and uterus are absent post-surgery.
Applicable To
- Post-hysterectomy status with removal of cervix
Excludes
- Congenital absence of cervix and uterus
Clinical Validation Requirements
- Operative report confirming removal of both cervix and uterus
- Patient history indicating total hysterectomy
Code-Specific Risks
- Incorrectly coding when cervix is retained
Coding Notes
- Ensure documentation specifies whether the cervix was removed to avoid incorrect coding.
Z90.711 - Acquired absence of uterus with remaining cervical stump
Use when the uterus is removed but the cervix remains.
Applicable To
- Post-hysterectomy status with cervical stump retained
Excludes
- Congenital absence of uterus
Clinical Validation Requirements
- Operative report indicating cervix was not removed
- Patient history confirming supracervical hysterectomy
Coding Notes
Verify cervical status in operative notes to ensure accurate coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Uterovaginal prolapse
N81.2Differential 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 Hysterectomy Status to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.710.
Impact
Clinical: Leads to incorrect patient management decisions., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or audits.
Mitigation Strategy
Use checklists in operative reports, Regular training on documentation standards
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records affecting clinical decisions.
Mitigation Strategy
Verify operative notes to confirm cervix removal before coding.
Impact
Risk of incorrect coding due to missing cervical status.
Mitigation Strategy
Implement regular audits of operative 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 Hysterectomy Status, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hysterectomy Status
Use these documentation templates to ensure complete and accurate documentation for Hysterectomy Status. These templates include all required elements for proper coding and billing.
Post-Hysterectomy Follow-Up
Specialty: GynecologyRequired Elements
- Patient history
- Operative details
- Cervical status
- Uterus weight
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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