ICD-10 Coding for Uterine Mass(C54.1, C79.82)
Complete ICD-10-CM coding and documentation guide for Uterine Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Mass
C54-C55Primary Range
Malignant neoplasms of corpus uteri
This range includes codes for malignant neoplasms of the uterine corpus, including endometrial cancer.
Other noninflammatory disorders of uterus
This range includes codes for non-malignant uterine disorders, such as adenomyosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C54.1 | Malignant neoplasm of endometrium | Use when there is a confirmed diagnosis of endometrial cancer. |
|
| C79.82 | Secondary malignant neoplasm of genital organs | Use when the uterine mass is a result of metastasis from another primary site. |
|
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 mass
Essential facts and insights about Uterine Mass
Primary ICD-10-CM Codes for uterine mass
Decision Criteria
clinical Criteria
- Biopsy confirms endometrial adenocarcinoma.
coding Criteria
- Use C54.1 for confirmed malignancy.
Applicable To
- Endometrial adenocarcinoma
Excludes
- Benign endometrial polyps
Clinical Validation Requirements
- Biopsy confirmation of endometrial adenocarcinoma
- Imaging showing endometrial mass
Code-Specific Risks
- Misclassification if biopsy is not confirmed
Coding Notes
- Ensure biopsy confirmation before coding as malignant.
C79.82 - Secondary malignant neoplasm of genital organs
Use when the uterine mass is a result of metastasis from another primary site.
Applicable To
- Metastatic cancer to uterus
Excludes
- Primary uterine cancer
Clinical Validation Requirements
- Histological confirmation of metastatic disease
- Primary site of cancer identified
Coding Notes
Ensure primary site is coded first.
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 Uterine Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C54.1.
Impact
Clinical: Misleading diagnosis and treatment plan., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always document the primary site of cancer., Use appropriate codes for primary and secondary sites.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of health data.
Mitigation Strategy
Always confirm histology to use specific codes like C54.1.
Impact
Risk of coding errors without biopsy confirmation.
Mitigation Strategy
Implement mandatory biopsy confirmation for all suspected malignancies.
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 Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Mass
Use these documentation templates to ensure complete and accurate documentation for Uterine Mass. These templates include all required elements for proper coding and billing.
Postmenopausal bleeding with uterine mass
Specialty: Gynecologic OncologyRequired Elements
- Patient history
- Imaging findings
- Biopsy results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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