ICD-10 Coding for Hysterectomy(Z90.710, Z90.711)
Complete ICD-10-CM coding and documentation guide for Hysterectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hysterectomy
Z90.710-Z90.711Primary Range
Acquired absence of uterus and cervix
These codes are used to indicate the status post-hysterectomy, not the procedure itself.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z90.710 | Acquired absence of both cervix and uterus | Use when documenting the absence of both uterus and cervix post-surgery. |
|
| Z90.711 | Acquired absence of uterus with remaining cervical stump | Use when documenting the absence of the uterus with the cervix remaining post-surgery. |
|
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 hysterectomy
Essential facts and insights about Hysterectomy
Primary ICD-10-CM Codes for hysterectomy
Decision Criteria
documentation Criteria
- Documentation must confirm both uterus and cervix are absent.
Applicable To
- Status post total hysterectomy
Excludes
- Congenital absence of uterus (Q51.0)
Clinical Validation Requirements
- Operative report confirming removal of uterus and cervix
Code-Specific Risks
- Ensure documentation specifies both uterus and cervix are absent.
Coding Notes
- This code is used for status post-procedure documentation.
Z90.711 - Acquired absence of uterus with remaining cervical stump
Use when documenting the absence of the uterus with the cervix remaining post-surgery.
Applicable To
- Status post subtotal hysterectomy
Excludes
- Congenital absence of uterus (Q51.0)
Clinical Validation Requirements
- Operative report confirming removal of uterus with cervix retained
Coding Notes
This code is used for status post-procedure documentation.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hysterectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.710.
Impact
Clinical: May lead to incorrect clinical interpretation., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Use specific terminology, Include all relevant details
Impact
Reimbursement: Incorrect CPT code selection may lead to improper reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data recording.
Mitigation Strategy
Ensure uterus weight is documented in the operative report or pathology report.
Impact
Selecting the wrong CPT code due to missing documentation.
Mitigation Strategy
Ensure complete and accurate documentation of all procedure details.
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 Hysterectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hysterectomy
Use these documentation templates to ensure complete and accurate documentation for Hysterectomy. These templates include all required elements for proper coding and billing.
Total Laparoscopic Hysterectomy
Specialty: GynecologyRequired Elements
- Procedure type
- Approach
- Uterus weight
- Specimens removed
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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