ICD-10 Coding for Elevated CA-125(R97.1, C56)
Complete ICD-10-CM coding and documentation guide for Elevated CA-125. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Elevated CA-125
R97-R97.9Primary Range
Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
This range includes codes for abnormal tumor markers, specifically R97.1 for elevated CA-125.
Neoplasms
Relevant for coding malignancies associated with elevated CA-125, such as ovarian cancer (C56).
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R97.1 | Elevated cancer antigen 125 [CA 125] | Use when CA-125 is elevated without a confirmed malignancy diagnosis. |
|
| C56 | Malignant neoplasm of ovary | Use as primary code when ovarian cancer is confirmed. |
|
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 elevated CA-125
Essential facts and insights about Elevated CA-125
Primary ICD-10-CM Codes for elevated carcinoma 125
Decision Criteria
clinical Criteria
- CA-125 level above normal range with clinical suspicion of malignancy
coding Criteria
- Use R97.1 when CA-125 is elevated but no malignancy is confirmed
Applicable To
- Elevated CA-125 levels
Excludes
- Malignant neoplasm of ovary (C56)
Clinical Validation Requirements
- CA-125 level above 35 U/mL
- Clinical context such as ovarian mass or history of malignancy
Code-Specific Risks
- Incorrectly using as primary code when malignancy is present
Coding Notes
- Ensure clinical documentation supports the use of R97.1, especially in the absence of a confirmed malignancy.
C56 - Malignant neoplasm of ovary
Use as primary code when ovarian cancer is confirmed.
Applicable To
- Ovarian cancer
Excludes
- Benign neoplasm of ovary (D27)
Clinical Validation Requirements
- Histological confirmation of ovarian cancer
- Imaging evidence of ovarian mass
Coding Notes
Ensure that C56 is sequenced before R97.1 when ovarian cancer is confirmed.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Malignant neoplasm of ovary
C56Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Elevated CA-125 to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R97.1.
Impact
Clinical: May lead to misinterpretation of lab results., Regulatory: Increases risk of audit due to incomplete documentation., Financial: Potential for denied claims due to lack of supporting documentation.
Mitigation Strategy
Always include clinical context in documentation., Ensure lab results are accompanied by relevant clinical findings.
Impact
Reimbursement: Incorrect sequencing can lead to reduced reimbursement., Compliance: May trigger audits for incorrect coding., Data Quality: Affects accuracy of patient records and data reporting.
Mitigation Strategy
Sequence C56 as primary and R97.1 as secondary.
Impact
Using R97.1 as primary code when malignancy is present.
Mitigation Strategy
Educate coders on proper sequencing rules and provide regular audits.
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 Elevated CA-125, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated CA-125
Use these documentation templates to ensure complete and accurate documentation for Elevated CA-125. These templates include all required elements for proper coding and billing.
Monitoring elevated CA-125 in ovarian cancer
Specialty: OncologyRequired Elements
- CA-125 level
- Clinical context
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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