ICD-10 Coding for Pituitary Macroadenoma(D35.2, E22.1)
Complete ICD-10-CM coding and documentation guide for Pituitary Macroadenoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pituitary Macroadenoma
Malignant neoplasms of endocrine glands
Used if pathology confirms malignancy of the pituitary gland.
Hyperfunction and hypofunction of pituitary gland
Covers functional disorders caused by pituitary tumors.
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 | For non-functional macroadenomas >1 cm without hormone excess. |
|
| E22.1 | Hyperprolactinemia | For prolactin-secreting macroadenomas. |
|
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 macroadenoma
Essential facts and insights about Pituitary Macroadenoma
Primary ICD-10-CM Codes for pituitary macroadenoma
Decision Criteria
clinical Criteria
- MRI shows a sellar mass >1 cm.
Applicable To
- Non-functioning pituitary macroadenoma
Excludes
- Malignant neoplasm of pituitary gland (C75.1)
Clinical Validation Requirements
- MRI showing >1 cm sellar mass
- Pathology confirming benign adenoma
Code-Specific Risks
- Ensure tumor size is documented to avoid queries.
Coding Notes
- Document tumor size and secretory status clearly.
E22.1 - Hyperprolactinemia
For prolactin-secreting macroadenomas.
Applicable To
- Prolactin-secreting pituitary adenoma
Excludes
- Non-functioning pituitary adenoma (D35.2)
Clinical Validation Requirements
- Prolactin >200 ng/mL
- Absence of macroprolactinemia
Coding Notes
Ensure prolactin levels are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Abnormal results of endocrine function studies
R94.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Pituitary Macroadenoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D35.2.
Impact
Clinical: Inaccurate clinical assessment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Standardize MRI reporting templates., Educate clinicians on documentation standards.
Impact
Reimbursement: Potential denial due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Always document and code tumor size >1 cm.
Impact
Lack of tumor size documentation leads to coding errors.
Mitigation Strategy
Implement mandatory fields in EHR for tumor size.
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 Macroadenoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pituitary Macroadenoma
Use these documentation templates to ensure complete and accurate documentation for Pituitary Macroadenoma. These templates include all required elements for proper coding and billing.
Non-functioning pituitary macroadenoma
Specialty: EndocrinologyRequired Elements
- Tumor size
- Secretory status
- MRI findings
- Endocrine lab results
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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