ICD-10 Coding for Uterine Cancer(C54.1, C54.2, C55)
Complete ICD-10-CM coding and documentation guide for Uterine Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Cancer
C54-C55Primary Range
Malignant neoplasms of the uterus
This range includes specific codes for different parts of the uterus, such as the endometrium and myometrium, as well as unspecified sites.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C54.1 | Malignant neoplasm of endometrium | Use when biopsy confirms endometrial adenocarcinoma. |
|
| C54.2 | Malignant neoplasm of myometrium | Use when biopsy confirms myometrial sarcoma. |
|
| C55 | Malignant neoplasm of uterus, part unspecified | Use when the specific site within the uterus cannot be determined. |
|
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 uterine cancer
Essential facts and insights about Uterine Cancer
Primary ICD-10-CM Codes for uterine cancer
Decision Criteria
clinical Criteria
- Confirmed endometrial origin via biopsy
coding Criteria
- Use for primary endometrial cancer
Applicable To
- Endometrial adenocarcinoma
Excludes
- Benign neoplasms of endometrium
Clinical Validation Requirements
- Biopsy confirming endometrial origin
- Imaging showing tumor confined to endometrium/myometrium
Code-Specific Risks
- Misclassification if histology is not confirmed
Coding Notes
- Ensure histological confirmation before coding.
C54.2 - Malignant neoplasm of myometrium
Use when biopsy confirms myometrial sarcoma.
Applicable To
- Leiomyosarcoma
Excludes
- Benign neoplasms of myometrium
Clinical Validation Requirements
- Biopsy confirming myometrial origin
- Absence of endometrial involvement
Coding Notes
Ensure myometrial origin is confirmed.
C55 - Malignant neoplasm of uterus, part unspecified
Use when the specific site within the uterus cannot be determined.
Applicable To
- Unspecified uterine malignancy
Excludes
- Specific sites within the uterus
Clinical Validation Requirements
- Biopsy unable to confirm specific site
- Imaging inconclusive for specific site
Coding Notes
Use only when specific site cannot be determined.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.6Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uterine Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C54.1.
Impact
Clinical: Misrepresentation of patient condition., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denial.
Mitigation Strategy
Verify histology before coding, Use N85.02 for hyperplasia without atypia
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation in patient records.
Mitigation Strategy
Code C54.1 if biopsy confirms endometrial origin, even if staging is pending.
Impact
Lack of specific histology documentation can lead to coding errors.
Mitigation Strategy
Ensure biopsy results are documented and reviewed 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 Uterine Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Cancer
Use these documentation templates to ensure complete and accurate documentation for Uterine Cancer. These templates include all required elements for proper coding and billing.
Endometrial cancer diagnosis
Specialty: OncologyRequired Elements
- Histology type
- Staging
- Myometrial invasion
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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