ICD-10 Coding for History of Brain Tumor(Z85.841, Z86.011)
Complete ICD-10-CM coding and documentation guide for History of Brain Tumor. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Brain Tumor
Z85-Z86Primary Range
Personal history of malignant neoplasms and certain other neoplasms
This range includes codes for documenting a patient's history of neoplasms, both malignant and benign, which are no longer active.
Malignant neoplasms of brain and other parts of central nervous system
This range is relevant for coding active malignant brain tumors, which must be differentiated from historical cases.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z85.841 | Personal history of malignant neoplasm of brain | Use when the patient has a resolved malignant brain tumor with no current treatment. |
|
| Z86.011 | Personal history of benign neoplasm of brain | Use when the patient has a resolved benign brain tumor with no current treatment. |
|
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 history of brain tumor
Essential facts and insights about History of Brain Tumor
Primary ICD-10-CM Codes for history of brain tumor
Decision Criteria
clinical Criteria
- Patient has no active brain tumor and no ongoing treatment.
documentation Criteria
- MRI/CT shows no evidence of disease.
Applicable To
- History of malignant brain tumor
Excludes
- Current malignant neoplasm of brain (C71.9)
Clinical Validation Requirements
- Absence of tumor on MRI/CT
- No active treatment orders
- Pathology confirming prior malignancy
Code-Specific Risks
- Confusing with active cancer codes
- Using during active treatment phase
Coding Notes
- Ensure documentation clearly states the tumor is resolved and no active treatment is ongoing.
Z86.011 - Personal history of benign neoplasm of brain
Use when the patient has a resolved benign brain tumor with no current treatment.
Applicable To
- History of benign brain tumor
Excludes
- Current benign neoplasm of brain (D33.0)
Clinical Validation Requirements
- Imaging showing stable/resected benign tumor
- Histology report confirming benign nature
Coding Notes
Documentation must confirm the benign nature and resolved status of the tumor.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Follow-up examination after treatment for malignant neoplasm
Z08Differential 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 History of Brain Tumor to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.841.
Impact
Clinical: Incomplete clinical picture for patient care., Regulatory: Non-compliance with coding specificity requirements., Financial: Potential claim denials due to lack of specificity.
Mitigation Strategy
Always specify laterality and anatomic site in documentation.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Ensure the tumor is resolved and no active treatment is ongoing before using history codes.
Impact
Using history codes when the patient is still undergoing treatment can trigger audits.
Mitigation Strategy
Ensure documentation clearly states the tumor is resolved and no active treatment is ongoing.
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 History of Brain Tumor, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Brain Tumor
Use these documentation templates to ensure complete and accurate documentation for History of Brain Tumor. These templates include all required elements for proper coding and billing.
Resolved Malignant Brain Tumor
Specialty: NeurologyRequired Elements
- Tumor type and behavior
- Date of last treatment
- Current status
- Anatomic site
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for History of Brain Tumor? Ask your questions below.