ICD-10 Coding for Total Abdominal Hysterectomy(Z90.710, Z90.711)
Complete ICD-10-CM coding and documentation guide for Total Abdominal Hysterectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Total Abdominal Hysterectomy
Z90.710-Z90.711Primary Range
Acquired absence of uterus and cervix
These codes are used post-procedure to indicate the absence of the uterus and cervix following a 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 this code for female patients post total abdominal hysterectomy. |
|
| Z90.711 | Acquired absence of uterus with remaining cervix | Use this code for patients who have had a supracervical hysterectomy. |
|
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 total abdominal hysterectomy
Essential facts and insights about Total Abdominal Hysterectomy
Primary ICD-10-CM Codes for total abdominal hysterectomy
Decision Criteria
clinical Criteria
- Patient has undergone a total abdominal hysterectomy with removal of both uterus and cervix.
Applicable To
- Status post total hysterectomy
Excludes
- Congenital absence of uterus and cervix (Q51.0)
Clinical Validation Requirements
- Operative report confirming total abdominal hysterectomy
- Pathology report indicating removal of uterus and cervix
Code-Specific Risks
- Ensure documentation supports the complete removal of both uterus and cervix.
Coding Notes
- This code is used to indicate the status post-surgery and should be documented in follow-up visits.
Z90.711 - Acquired absence of uterus with remaining cervix
Use this code for patients who have had a supracervical hysterectomy.
Applicable To
- Status post supracervical hysterectomy
Excludes
- Congenital absence of uterus (Q51.0)
Clinical Validation Requirements
- Operative report confirming removal of uterus with cervix intact
Coding Notes
This code is used to indicate the status post-surgery where the cervix is retained.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Total Abdominal 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: Patient may not be fully informed of procedure risks., Regulatory: Non-compliance with consent regulations., Financial: Potential claim denials from payers.
Mitigation Strategy
Ensure consent forms are signed and filed before surgery., Verify consent documentation during pre-op checklist.
Impact
Reimbursement: Incorrect coding can affect DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate medical records and potential audit issues.
Mitigation Strategy
Ensure operative reports include uterus weight or query the provider.
Impact
Failure to document uterus weight can lead to incorrect coding.
Mitigation Strategy
Ensure weight is documented in operative and pathology reports.
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 Total Abdominal Hysterectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Total Abdominal Hysterectomy
Use these documentation templates to ensure complete and accurate documentation for Total Abdominal Hysterectomy. These templates include all required elements for proper coding and billing.
Total Abdominal Hysterectomy for Uterine Fibroids
Specialty: GynecologyRequired Elements
- Surgical approach
- Uterus weight
- Extent of surgery
- Pathology correlation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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