ICD-10 Coding for Left Adnexal Mass(N83.292, C56.2)
Complete ICD-10-CM coding and documentation guide for Left Adnexal Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Adnexal Mass
N83.2-N83.9Primary Range
Noninflammatory disorders of ovary, fallopian tube and broad ligament
This range includes codes for benign and noninflammatory disorders of the left ovary, including cysts and other adnexal masses.
Malignant neoplasms of ovary and other uterine adnexa
This range includes codes for malignant neoplasms of the left ovary, which are relevant if the adnexal mass is confirmed as malignant.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N83.292 | Other ovarian cyst, left side | Use when imaging confirms a benign cystic structure on the left ovary. |
|
| C56.2 | Malignant neoplasm of left ovary | Use when malignancy is confirmed by biopsy or imaging. |
|
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 left adnexal mass
Essential facts and insights about Left Adnexal Mass
Primary ICD-10-CM Codes for left adnexal mass
Decision Criteria
clinical Criteria
- Presence of a simple cyst on ultrasound
documentation Criteria
- Clear documentation of cyst size and characteristics
Applicable To
- Benign left ovarian cyst
Excludes
- Malignant neoplasm of ovary (C56.2)
Clinical Validation Requirements
- Ultrasound showing unilocular, anechoic cyst
- No symptoms or mild symptoms
Code-Specific Risks
- Misclassification if malignancy is suspected but not ruled out
Coding Notes
- Ensure laterality is documented to avoid unspecified codes.
C56.2 - Malignant neoplasm of left ovary
Use when malignancy is confirmed by biopsy or imaging.
Applicable To
- Primary ovarian cancer, left side
Excludes
- Benign ovarian cyst (N83.292)
Clinical Validation Requirements
- Histopathology confirming malignancy
- Elevated CA-125 levels
Coding Notes
Ensure malignancy is documented with supporting evidence.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Adnexal Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N83.292.
Impact
Clinical: May lead to incorrect treatment planning., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Always include laterality in clinical notes., Verify imaging reports for side specification.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Reduces the accuracy of health data.
Mitigation Strategy
Always use codes that specify the left side when documentation supports it.
Impact
Failure to document laterality can lead to audit findings.
Mitigation Strategy
Implement a checklist to ensure laterality is documented in all relevant cases.
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 Left Adnexal Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Adnexal Mass
Use these documentation templates to ensure complete and accurate documentation for Left Adnexal Mass. These templates include all required elements for proper coding and billing.
Initial evaluation of left adnexal mass
Specialty: GynecologyRequired Elements
- Patient history
- Ultrasound findings
- CA-125 levels
- Menopausal status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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