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ICD-10 Coding for Tubo-Oophorectomy(N83.201, C56.9)

Complete ICD-10-CM coding and documentation guide for Tubo-Oophorectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Salpingo-OophorectomyAdnexectomy

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Related ICD-10 Code Ranges

Complete code families applicable to Tubo-Oophorectomy

N83-N84Primary Range

Noninflammatory disorders of ovary, fallopian tube and broad ligament

This range includes conditions that may necessitate a tubo-oophorectomy, such as ovarian cysts and other adnexal masses.

C56-C57

Malignant neoplasms of ovary and other uterine adnexa

This range covers malignant conditions that may require a tubo-oophorectomy as part of treatment.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
N83.201Unspecified ovarian cyst, right sideUse when an ovarian cyst is identified on the right side and requires surgical intervention.
  • Imaging studies confirming cyst presence
  • Clinical symptoms such as pelvic pain
C56.9Malignant neoplasm of unspecified ovaryUse when ovarian cancer is confirmed but laterality is not specified.
  • Pathology report confirming malignancy
  • Elevated CA-125 levels

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 tubo-oophorectomy

Essential facts and insights about Tubo-Oophorectomy

The ICD-10 code for tubo-oophorectomy varies based on the condition, such as N83.201 for an unspecified ovarian cyst on the right side.

Primary ICD-10-CM Codes for tubo oophorectomy

N83.201
Unspecified ovarian cyst, right side
Billable Code

Decision Criteria

clinical Criteria

  • Presence of a cyst on imaging studies

documentation Criteria

  • Clear documentation of laterality

Applicable To

  • Ovarian cysts

Excludes

  • Malignant neoplasm of ovary (C56)

Clinical Validation Requirements

  • Imaging studies confirming cyst presence
  • Clinical symptoms such as pelvic pain

Code-Specific Risks

  • Incorrect laterality documentation

Coding Notes

  • Ensure laterality is documented clearly to avoid coding errors.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Prophylactic organ removal for prevention of malignancy

Z40.02
Use when the procedure is performed as a preventive measure in high-risk patients.

Personal history of malignant neoplasm of ovary

Z85.43
Use for patients with a history of ovarian cancer.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Malignant neoplasm of right ovary

C56.1
Use C56.1 if malignancy is confirmed via pathology.

Unspecified ovarian cyst, left side

N83.202
Use N83.202 if the condition is a benign cyst rather than a malignancy.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Tubo-Oophorectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N83.201.

Impact

Clinical: Potential for incorrect treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Denial of claims due to incomplete information.

Mitigation Strategy

Use templates that prompt for laterality, Double-check documentation before submission

Impact

Reimbursement: Claims may be denied or delayed due to incorrect coding., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.

Mitigation Strategy

Ensure laterality is documented and coded correctly.

Impact

Failure to document laterality can lead to audit issues.

Mitigation Strategy

Implement mandatory laterality checks in documentation workflows.

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 Tubo-Oophorectomy, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Tubo-Oophorectomy

Use these documentation templates to ensure complete and accurate documentation for Tubo-Oophorectomy. These templates include all required elements for proper coding and billing.

Laparoscopic Bilateral Salpingo-Oophorectomy

Specialty: Gynecologic Oncology

Required Elements

  • Procedure details
  • Specimen integrity
  • Laterality
  • Pathology findings

Example Documentation

PROCEDURE: Laparoscopic bilateral salpingo-oophorectomy. INDICATIONS: BRCA2+ patient with ovarian cysts. SPECIMEN: Right ovary intact, left ovary with cyst. PATHOLOGY: No malignancy.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Removed ovaries and tubes.
Good Documentation Example
Performed laparoscopic bilateral salpingo-oophorectomy for BRCA2+ patient. Right ovary intact, left ovary with cyst. Pathology confirmed no malignancy.
Explanation
The good example provides specific details about the procedure, laterality, and pathology findings, which are essential for accurate coding and billing.

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