ICD-10 Coding for Total Hysterectomy(0UT94ZZ, Z90.710)
Complete ICD-10-CM coding and documentation guide for Total Hysterectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Total Hysterectomy
0UT90ZZ-0UT97ZZPrimary Range
ICD-10-PCS codes for total hysterectomy procedures
These codes cover the surgical removal of the uterus and cervix through various approaches.
ICD-10-CM codes for acquired absence of uterus and cervix
These codes are used post-operatively to indicate the absence of the uterus and cervix.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| 0UT94ZZ | Resection of Uterus and Cervix, Percutaneous Endoscopic Approach | Use when a total hysterectomy is performed laparoscopically. |
|
| Z90.710 | Acquired absence of both cervix and uterus | Use for patients with documented absence of uterus and cervix post-surgery. |
|
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 hysterectomy
Essential facts and insights about Total Hysterectomy
Primary ICD-10-CM Codes for total hysterectomy
Decision Criteria
clinical Criteria
- Laparoscopic approach confirmed in operative report
Applicable To
- Total laparoscopic hysterectomy
Excludes
- Subtotal hysterectomy
Clinical Validation Requirements
- Operative report specifying laparoscopic approach
- Pathology report confirming resection of uterus and cervix
Code-Specific Risks
- Incorrect documentation of approach can lead to coding errors.
Coding Notes
- Ensure documentation specifies the approach and confirms complete resection.
Z90.710 - Acquired absence of both cervix and uterus
Use for patients with documented absence of uterus and cervix post-surgery.
Applicable To
- Post-total hysterectomy status
Clinical Validation Requirements
- Post-operative status documented in patient record
Coding Notes
Ensure post-operative status is clearly documented.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Resection of Uterus and Cervix, Open Approach
0UT90ZZDocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Total Hysterectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code 0UT94ZZ.
Impact
Clinical: Inaccurate surgical records., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or audits.
Mitigation Strategy
Ensure weight is recorded in operative notes.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with updated coding guidelines., Data Quality: Inaccurate medical records affecting patient care.
Mitigation Strategy
Use single code 0UT94ZZ for total hysterectomy post-2017.
Impact
Using outdated codes for total hysterectomy.
Mitigation Strategy
Regular training on coding updates and guidelines.
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 Hysterectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Total Hysterectomy
Use these documentation templates to ensure complete and accurate documentation for Total Hysterectomy. These templates include all required elements for proper coding and billing.
Total Laparoscopic Hysterectomy
Specialty: GynecologyRequired Elements
- Procedure type
- Approach
- Uterus weight
- Cervix status
- Adnexa removal
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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