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ICD-10 Coding for History of Endometrial Cancer(Z85.42, C54.1)

Complete ICD-10-CM coding and documentation guide for History of Endometrial Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Post-treatment Endometrial CancerEndometrial Cancer Surveillancehistory of uterine cancerhx endometrial cancerpast endometrial cancer

Related ICD-10 Code Ranges

Complete code families applicable to History of Endometrial Cancer

Z85-Z99Primary Range

Persons with potential health hazards related to family and personal history and certain conditions influencing health status

This range includes codes for personal history of malignant neoplasms, including endometrial cancer.

Malignant neoplasms of corpus uteri and uterus, part unspecified

This range includes active cancer codes for endometrial cancer, used when the disease is active or recurrent.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
Z85.42Personal history of malignant neoplasm of other parts of uterusUse after all treatment is completed and there is no evidence of disease.
  • No evidence of disease on imaging or biopsy
  • Completed treatment with no current symptoms
C54.1Malignant neoplasm of endometriumUse when the cancer is active or there is confirmed recurrence.
  • Positive biopsy or imaging indicating active disease

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 endometrial cancer

Essential facts and insights about History of Endometrial Cancer

The ICD-10 code for history of endometrial cancer is Z85.42, used post-treatment with no evidence of disease.

Primary ICD-10-CM Codes for history of endometrial cancer

Personal history of malignant neoplasm of other parts of uterus
Billable Code

Decision Criteria

clinical Criteria

  • Patient has completed all treatment and shows no evidence of disease.

coding Criteria

  • Use Z85.42 with Z08 for follow-up visits.

Applicable To

  • History of endometrial cancer

Excludes

  • Current or active endometrial cancer (C54.1)

Clinical Validation Requirements

  • No evidence of disease on imaging or biopsy
  • Completed treatment with no current symptoms

Code-Specific Risks

  • Incorrectly using during active treatment phase

Coding Notes

  • Ensure documentation clearly states 'no evidence of disease' and treatment completion.

Ancillary Codes

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

Encounter for follow-up examination after completed treatment for malignant neoplasm

Z08
Use as primary code during surveillance visits.

Differential Codes

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

Malignant neoplasm of endometrium

C54.1
Use C54.1 if the cancer is active or there is recurrence.

Personal history of malignant neoplasm of other parts of uterus

Z85.42
Use Z85.42 if the patient is in remission with no active disease.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting History of Endometrial Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.42.

Impact

Clinical: May lead to inappropriate follow-up care., Regulatory: Could trigger audits due to lack of specificity., Financial: Potential for denied claims due to insufficient documentation.

Mitigation Strategy

Ensure detailed history is documented, Include specific dates and treatment details

Impact

Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: May result in audit discrepancies., Data Quality: Affects accuracy of patient records.

Mitigation Strategy

Use C54.1 if treatment is ongoing or cancer is active.

Impact

Failure to sequence Z08 before Z85.42 in surveillance visits.

Mitigation Strategy

Educate coding staff on proper sequencing rules.

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 Endometrial Cancer, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for History of Endometrial Cancer

Use these documentation templates to ensure complete and accurate documentation for History of Endometrial Cancer. These templates include all required elements for proper coding and billing.

Post-treatment surveillance

Specialty: Oncology

Required Elements

  • Treatment history
  • Current surveillance plan
  • Recent test results

Example Documentation

Patient completed total laparoscopic hysterectomy and chemotherapy in 2020 for endometrial adenocarcinoma. No evidence of recurrence on recent CT scan. Currently on routine surveillance with CA-125 within normal limits.

Examples: Poor vs. Good Documentation

Poor Documentation Example
History of uterine cancer.
Good Documentation Example
History of stage IA endometrial adenocarcinoma, status post total laparoscopic hysterectomy with BSO in 2020, completed adjuvant chemotherapy 6/2020. No evidence of recurrence on 3/2025 CT pelvis. Current encounter for routine surveillance per NCCN guidelines.
Explanation
The good example provides specific details about the treatment history, current status, and surveillance plan.

Need help with ICD-10 coding for History of Endometrial Cancer? Ask your questions below.

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