ICD-10 Coding for Pituitary Adenoma(D35.2, E23.6)
Complete ICD-10-CM coding and documentation guide for Pituitary Adenoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pituitary Adenoma
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| D35.2 | Benign neoplasm of pituitary gland | Use when a benign pituitary adenoma is confirmed by histology. |
|
| E23.6 | Other disorders of pituitary gland | Use when there is hormonal dysfunction related to the pituitary gland without a confirmed neoplasm. |
|
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 pituitary adenoma
Essential facts and insights about Pituitary Adenoma
Primary ICD-10-CM Codes for pituitary adenoma
Decision Criteria
clinical Criteria
- Histopathology confirms benign adenoma.
Applicable To
- Nonfunctional pituitary adenoma
- Functional pituitary adenoma with hormonal documentation
Excludes
- Malignant neoplasm of pituitary gland (C75.1)
Clinical Validation Requirements
- Histopathology report confirming adenoma
- Immunohistochemistry results
Code-Specific Risks
- Misclassification if histology is not confirmed
Coding Notes
- Ensure histopathology confirms benign nature before coding.
E23.6 - Other disorders of pituitary gland
Use when there is hormonal dysfunction related to the pituitary gland without a confirmed neoplasm.
Applicable To
- Hypopituitarism secondary to adenoma
Excludes
- Primary pituitary adenoma (D35.2)
Clinical Validation Requirements
- Documentation of hormonal dysfunction without confirmed neoplasm
Coding Notes
Ensure hormonal dysfunction is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Abnormal endocrine function studies
R94.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Pituitary Adenoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D35.2.
Impact
Clinical: Incomplete clinical picture., Regulatory: Potential audit issues., Financial: Missed reimbursement opportunities.
Mitigation Strategy
Review hormonal lab results., Ensure all relevant codes are used.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on tumor prevalence.
Mitigation Strategy
Ensure histopathology report confirms adenoma before coding.
Impact
Lack of histopathology confirmation for adenoma coding.
Mitigation Strategy
Require histopathology report 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 Pituitary Adenoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pituitary Adenoma
Use these documentation templates to ensure complete and accurate documentation for Pituitary Adenoma. These templates include all required elements for proper coding and billing.
Post-operative documentation for pituitary adenoma resection
Specialty: NeurosurgeryRequired Elements
- Pre-op diagnosis
- Post-op findings
- Procedure details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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