ICD-10 Coding for Personal History of Endometrial Cancer(Z85.42)
Complete ICD-10-CM coding and documentation guide for Personal History of Endometrial Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Personal History of Endometrial Cancer
Z85.42Primary Range
Personal history of malignant neoplasm of other parts of uterus
This code is used to document a patient's history of endometrial cancer after treatment has been completed and there is no active disease.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Used in conjunction with Z85.42 for surveillance visits post-treatment.
Key Information: ICD-10 code for personal history of endometrial cancer
Essential facts and insights about Personal History of Endometrial Cancer
Primary ICD-10-CM Code for personal history of endometrial cancer
Decision Criteria
clinical Criteria
- Patient has completed all cancer treatment and is in remission.
documentation Criteria
- Imaging shows no evidence of disease.
Applicable To
- History of endometrial cancer
Excludes
- Current malignant neoplasm of endometrium (C54.1)
Clinical Validation Requirements
- No evidence of active disease on imaging
- Completed treatment documented
- Surveillance plan in place
Code-Specific Risks
- Incorrectly using this code when the patient is still undergoing treatment.
Coding Notes
- Ensure documentation specifies the endometrial origin of the cancer.
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 Personal 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: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Always specify 'endometrial' when documenting history of uterine cancer.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Confirm treatment completion and remission status before using Z85.42.
Impact
Using Z85.42 for patients still under treatment.
Mitigation Strategy
Verify treatment status and remission before coding.
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 Personal History of Endometrial Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Personal History of Endometrial Cancer
Use these documentation templates to ensure complete and accurate documentation for Personal History of Endometrial Cancer. These templates include all required elements for proper coding and billing.
Routine Surveillance Post-Endometrial Cancer Treatment
Specialty: OncologyRequired Elements
- Patient history of endometrial cancer
- Treatment completion date
- Current surveillance plan
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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