ICD-10 Coding for Leiomyosarcoma(C49.-, C55.9)
Complete ICD-10-CM coding and documentation guide for Leiomyosarcoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Leiomyosarcoma
C49.-Primary Range
Malignant neoplasm of connective and soft tissue
Primary range for coding leiomyosarcoma based on the site of origin in connective or soft tissue.
Malignant neoplasm of uterus, unspecified
Used for uterine leiomyosarcoma, the most common site for this condition.
Secondary and unspecified malignant neoplasm of lymph nodes
Used for metastatic leiomyosarcoma with lymph node involvement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C49.- | Malignant neoplasm of connective and soft tissue | Use when leiomyosarcoma originates in connective or soft tissue. |
|
| C55.9 | Malignant neoplasm of uterus, unspecified | Use for leiomyosarcoma originating in the uterus. |
|
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 leiomyosarcoma
Essential facts and insights about Leiomyosarcoma
Primary ICD-10-CM Codes for leiomyosarcoma
Decision Criteria
clinical Criteria
- Confirmed soft tissue origin via imaging and biopsy.
Applicable To
- Leiomyosarcoma of soft tissue
Excludes
- Benign neoplasms of soft tissue
Clinical Validation Requirements
- Histopathology confirming smooth muscle differentiation
- Immunohistochemistry positive for desmin, SMA
Code-Specific Risks
- Misclassification if morphology code is not appended.
Coding Notes
- Ensure primary site is confirmed through pathology.
C55.9 - Malignant neoplasm of uterus, unspecified
Use for leiomyosarcoma originating in the uterus.
Applicable To
- Uterine leiomyosarcoma
Excludes
- Benign uterine neoplasms
Clinical Validation Requirements
- Histopathology confirming uterine origin
- Immunohistochemistry positive for smooth muscle markers
Coding Notes
Confirm uterine origin with histopathology.
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 Leiomyosarcoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C49.-.
Impact
Clinical: Misclassification of cancer type., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential underpayment due to incorrect DRG.
Mitigation Strategy
Review pathology reports for histological confirmation., Ensure morphology code is appended to primary site code.
Impact
Reimbursement: Incorrect DRG assignment leading to underpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data affecting cancer registries.
Mitigation Strategy
Require pathology stating 'malignant smooth muscle tumor'.
Impact
Failure to include morphology code 8890/3 with primary site code.
Mitigation Strategy
Implement coding audits to ensure morphology codes are used.
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 Leiomyosarcoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Leiomyosarcoma
Use these documentation templates to ensure complete and accurate documentation for Leiomyosarcoma. These templates include all required elements for proper coding and billing.
Primary retroperitoneal leiomyosarcoma
Specialty: OncologyRequired Elements
- Primary site confirmation
- Histopathology results
- Immunohistochemistry markers
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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