ICD-10 Coding for Status Post Hysterectomy(Z90.710, Z90.711)
Complete ICD-10-CM coding and documentation guide for Status Post Hysterectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Status Post Hysterectomy
Z90.71-Z90.79Primary Range
Acquired absence of organs, not elsewhere classified
This range includes codes for the acquired absence of the uterus, which is the primary focus for status post hysterectomy.
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 documenting a total hysterectomy where both the cervix and uterus have been removed. |
|
| Z90.711 | Acquired absence of uterus with remaining cervical stump | Use when documenting a subtotal hysterectomy where the cervix is retained. |
|
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 status post hysterectomy
Essential facts and insights about Status Post Hysterectomy
Primary ICD-10-CM Codes for status post hysterectomy
Decision Criteria
clinical Criteria
- Confirmation of total hysterectomy via operative report
documentation Criteria
- Operative notes must specify removal of cervix and uterus
Applicable To
- Total hysterectomy
Excludes
- Subtotal hysterectomy (Z90.711)
Clinical Validation Requirements
- Operative report confirming removal of both cervix and uterus
- Pathology report if operative report is unavailable
Code-Specific Risks
- Incorrectly using this code when the cervix is retained.
Coding Notes
- Ensure documentation clearly states the removal of both cervix and uterus.
Z90.711 - Acquired absence of uterus with remaining cervical stump
Use when documenting a subtotal hysterectomy where the cervix is retained.
Applicable To
- Subtotal hysterectomy
Excludes
- Total hysterectomy (Z90.710)
Clinical Validation Requirements
- Operative report confirming cervix is retained
- Pathology report if operative report is unavailable
Coding Notes
Ensure documentation clearly states the retention of the cervix.
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 Status Post Hysterectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.710.
Impact
Clinical: Inaccurate assessment of procedure complexity., Regulatory: Non-compliance with coding guidelines., Financial: Potential undercoding and reimbursement issues.
Mitigation Strategy
Ensure operative report includes uterine weight., Query surgeon if weight is not documented.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify operative report to confirm removal of cervix before coding.
Impact
Inaccurate or incomplete operative reports can lead to incorrect coding.
Mitigation Strategy
Regular audits of operative reports and coder training.
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 Status Post Hysterectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Status Post Hysterectomy
Use these documentation templates to ensure complete and accurate documentation for Status Post Hysterectomy. These templates include all required elements for proper coding and billing.
Gynecology Follow-Up Note
Specialty: GynecologyRequired Elements
- Procedure Date
- Procedure Type
- Cervical Status
- Adnexal Status
- Key Findings
- Current Symptoms
- Physical Exam
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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