ICD-10 Coding for Right Adnexal Mass(N83.291, C57.41)
Complete ICD-10-CM coding and documentation guide for Right Adnexal Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Adnexal Mass
N83.2-N83.8Primary Range
Noninflammatory disorders of ovary, fallopian tube and broad ligament
This range includes codes for noninflammatory disorders of the right adnexa, including cysts and other benign conditions.
Malignant neoplasm of other and unspecified female genital organs
This range is used for coding malignant neoplasms of the right adnexa.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N83.291 | Other ovarian cyst, right side | Use for simple cysts on the right ovary in premenopausal women. |
|
| C57.41 | Malignant neoplasm of right adnexa | Use when malignancy is confirmed by biopsy. |
|
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 right adnexal mass
Essential facts and insights about Right Adnexal Mass
Primary ICD-10-CM Codes for right adnexal mass
Decision Criteria
clinical Criteria
- Simple cyst on ultrasound, premenopausal status
Applicable To
- Right ovarian cyst
Excludes
- Malignant neoplasm of ovary (C56.-)
Clinical Validation Requirements
- Ultrasound showing simple cyst
- Premenopausal status
Code-Specific Risks
- Risk of undercoding if malignancy is suspected.
Coding Notes
- Ensure documentation specifies 'right' and 'cyst' to avoid unspecified coding.
C57.41 - Malignant neoplasm of right adnexa
Use when malignancy is confirmed by biopsy.
Applicable To
- Malignant tumor of right ovary
Excludes
- Benign neoplasm of ovary (D27.-)
Clinical Validation Requirements
- Biopsy confirming malignancy
- Elevated CA-125 in postmenopausal women
Coding Notes
Ensure malignancy is confirmed before coding.
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 Right Adnexal Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N83.291.
Impact
Clinical: May lead to inappropriate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Verify biopsy results before coding., Include oncologist's notes in the record.
Impact
Reimbursement: May lead to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases data specificity and quality.
Mitigation Strategy
Always use specific codes like N83.291 when laterality is known.
Impact
Failure to document laterality can lead to audit flags.
Mitigation Strategy
Ensure all reports specify 'right' or 'left' for adnexal masses.
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 Right Adnexal Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Adnexal Mass
Use these documentation templates to ensure complete and accurate documentation for Right Adnexal Mass. These templates include all required elements for proper coding and billing.
Right adnexal mass in a postmenopausal woman
Specialty: OB-GYNRequired Elements
- Ultrasound findings
- CA-125 levels
- Menopausal status
- O-RADS classification
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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