ICD-10 Coding for Pituitary Microadenoma(D35.2)
Complete ICD-10-CM coding and documentation guide for Pituitary Microadenoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pituitary Microadenoma
D35-D36Primary Range
Benign neoplasms
This range includes benign neoplasms of the pituitary gland, specifically D35.2 for pituitary microadenoma.
Disorders of other endocrine glands
This range includes endocrine disorders that may be associated with pituitary microadenomas, such as hyperprolactinemia.
Key Information: ICD-10 code for pituitary microadenoma
Essential facts and insights about Pituitary Microadenoma
Primary ICD-10-CM Code for pituitary microadenoma
Decision Criteria
clinical Criteria
- Tumor size <10mm confirmed by imaging
documentation Criteria
- Histopathology confirming benign nature
Applicable To
- Pituitary microadenoma
Excludes
- Malignant neoplasm of pituitary gland (C75.1)
Clinical Validation Requirements
- MRI findings showing tumor <10mm
- Histopathology confirming benign nature
Code-Specific Risks
- Incorrectly coding as malignant or uncertain behavior
Coding Notes
- Ensure tumor size and benign nature are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Hyperprolactinemia
E22.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Malignant neoplasm of pituitary gland
C75.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Pituitary Microadenoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D35.2.
Impact
Clinical: May affect treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Always document tumor size in millimeters.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on benign tumor prevalence.
Mitigation Strategy
Use D35.2 with path confirmation
Impact
Lack of size documentation can lead to audit flags.
Mitigation Strategy
Ensure all imaging reports include tumor size.
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 Microadenoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pituitary Microadenoma
Use these documentation templates to ensure complete and accurate documentation for Pituitary Microadenoma. These templates include all required elements for proper coding and billing.
Non-functioning pituitary microadenoma
Specialty: EndocrinologyRequired Elements
- Tumor size
- Endocrine function
- Imaging details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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