ICD-10 Coding for Pituitary Mass(D35.2, C75.1)
Complete ICD-10-CM coding and documentation guide for Pituitary Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pituitary Mass
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| D35.2 | Benign neoplasm of pituitary gland | Use when a benign pituitary tumor is confirmed by pathology. |
|
| C75.1 | Malignant neoplasm of pituitary gland | Use when a malignant pituitary tumor is confirmed. |
|
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 pituitary mass
Essential facts and insights about Pituitary Mass
Primary ICD-10-CM Codes for pituitary mass
Decision Criteria
clinical Criteria
- Benign histology confirmed
documentation Criteria
- Imaging and pathology reports available
Applicable To
- Pituitary adenoma
- Prolactinoma
Excludes
- Malignant neoplasm of pituitary gland (C75.1)
Clinical Validation Requirements
- Histopathological confirmation of benign tumor
- Imaging showing non-invasive characteristics
Code-Specific Risks
- Misclassification if malignancy is not ruled out
Coding Notes
- Ensure documentation specifies benign nature and any hormonal activity.
C75.1 - Malignant neoplasm of pituitary gland
Use when a malignant pituitary tumor is confirmed.
Applicable To
- Pituitary carcinoma
Excludes
- Benign neoplasm of pituitary gland (D35.2)
Clinical Validation Requirements
- Biopsy confirming malignancy
- Imaging showing invasive characteristics
Coding Notes
Ensure malignancy is documented with histological evidence.
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 Pituitary Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D35.2.
Impact
Clinical: Inadequate assessment of tumor progression., Regulatory: Non-compliance with documentation standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Always include size in imaging reports, Review documentation before finalizing
Impact
Reimbursement: Incorrect DRG assignment leading to reimbursement issues., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Verify histology reports to confirm benign nature before coding.
Impact
Inadequate documentation of histological findings.
Mitigation Strategy
Ensure all pathology reports are complete and reviewed.
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 Pituitary Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pituitary Mass
Use these documentation templates to ensure complete and accurate documentation for Pituitary Mass. These templates include all required elements for proper coding and billing.
Pituitary Adenoma Diagnosis
Specialty: EndocrinologyRequired Elements
- Histopathology report
- Imaging findings
- Endocrine function tests
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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