ICD-10 Coding for Uterine Leiomyosarcoma(C54.2, C55)
Complete ICD-10-CM coding and documentation guide for Uterine Leiomyosarcoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Leiomyosarcoma
C54-C55Primary Range
Malignant neoplasms of the uterus
This range includes codes for malignant neoplasms of the uterine corpus and unspecified parts of the uterus, relevant for coding uterine leiomyosarcoma.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C54.2 | Malignant neoplasm of myometrium | Use when the tumor is confirmed to originate in the myometrium. |
|
| C55 | Malignant neoplasm of uterus, part unspecified | Use when documentation does not specify the uterine subsite. |
|
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 uterine leiomyosarcoma
Essential facts and insights about Uterine Leiomyosarcoma
Primary ICD-10-CM Codes for uterine leiomyosarcoma
Decision Criteria
clinical Criteria
- Tumor confirmed in the myometrium with histological evidence.
Applicable To
- Leiomyosarcoma of the myometrium
Excludes
- Endometrial stromal sarcoma (C54.1)
Clinical Validation Requirements
- Histologic confirmation of smooth muscle origin
- Presence of spindle cells with nuclear pleomorphism
- Tumor cell necrosis
- Mitotic activity ≥10/10 HPF
Code-Specific Risks
- Misclassification with C55 if the site is specified as myometrium.
Coding Notes
- Ensure histological confirmation is documented to support the use of C54.2.
C55 - Malignant neoplasm of uterus, part unspecified
Use when documentation does not specify the uterine subsite.
Excludes
- Specific sites of the uterus (C54.-)
Clinical Validation Requirements
- Used when the specific site of the uterine tumor is not documented.
Coding Notes
Query the provider if the site can be specified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for antineoplastic radiation therapy
Z51.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uterine Leiomyosarcoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C54.2.
Impact
Clinical: May lead to inappropriate treatment planning., Regulatory: Non-compliance with coding specificity requirements., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure detailed site documentation in medical records., Educate providers on the importance of specifying tumor location.
Impact
Reimbursement: Incorrect coding may lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data for clinical and research purposes.
Mitigation Strategy
Use C54.2 when the tumor is confirmed in the myometrium.
Impact
High use of C55 without site specification can trigger audits.
Mitigation Strategy
Encourage detailed documentation of tumor site.
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 Uterine Leiomyosarcoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Leiomyosarcoma
Use these documentation templates to ensure complete and accurate documentation for Uterine Leiomyosarcoma. These templates include all required elements for proper coding and billing.
Pathology report for uterine leiomyosarcoma
Specialty: PathologyRequired Elements
- Tumor size
- Location
- Histology
- Mitotic count
- Necrosis
- Immunohistochemistry results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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