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ICD-10 Guide
ICD-10 CodesC54.9

C54.9

Billable

Malignant neoplasm of corpus uteri, unspecified

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 C54.9 is a billable code used to indicate a diagnosis of malignant neoplasm of corpus uteri, unspecified.

Key Diagnostic Point:

C54.9 refers to a malignant neoplasm located in the corpus uteri, which is the main body of the uterus. This code is used when the specific type of malignancy is not specified, making it essential for coders to ensure that all relevant clinical information is documented. The corpus uteri is a common site for gynecologic cancers, including endometrial carcinoma, which is the most prevalent type of uterine cancer. Symptoms may include abnormal vaginal bleeding, pelvic pain, and changes in menstrual patterns. Diagnosis typically involves imaging studies, biopsy, and histopathological examination. Staging of the cancer is crucial for treatment planning and prognosis, often utilizing the FIGO (International Federation of Gynecology and Obstetrics) staging system. CA-125, a tumor marker, may be elevated in cases of endometrial cancer, aiding in diagnosis and monitoring treatment response. Surgical approaches may include hysterectomy, which is the primary treatment for localized disease, and may be accompanied by lymphadenectomy to assess for metastasis. Understanding the nuances of this code is vital for accurate billing and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified nature of the neoplasm complicates coding.
  • Variability in staging and treatment options.
  • Need for precise documentation of symptoms and diagnostic tests.
  • Potential overlap with other gynecologic malignancies.

Audit Risk Factors

  • Inadequate documentation of the type of malignancy.
  • Failure to document staging and treatment plans.
  • Misinterpretation of symptoms leading to incorrect coding.
  • Lack of follow-up documentation post-treatment.

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed documentation of symptoms, imaging results, biopsy findings, and treatment plans.

Common Clinical Scenarios

Diagnosis of endometrial cancer, staging assessments, and treatment planning.

Billing Considerations

Ensure clarity in documentation regarding the type of malignancy and staging to avoid coding errors.

Oncology

Documentation Requirements

Comprehensive records of treatment regimens, response to therapy, and follow-up care.

Common Clinical Scenarios

Management of patients undergoing chemotherapy or radiation therapy for uterine cancer.

Billing Considerations

Accurate documentation of tumor markers like CA-125 and their relevance to treatment outcomes.

Coding Guidelines

Inclusion Criteria

Use C54.9 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when the specific type of malignancy is not documented
  • Include all relevant clinical information to support the diagnosis

Exclusion Criteria

Do NOT use C54.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Used for treatment of malignant neoplasm of the uterus.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Gynecologic oncologists should ensure comprehensive documentation of the malignancy type.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of malignancies, but C54.9 remains a challenge due to its unspecified nature. Coders must ensure thorough documentation to avoid misclassification.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of malignancies, but C54.9 remains a challenge due to its unspecified nature. Coders must ensure thorough documentation to avoid misclassification.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of malignancies, but C54.9 remains a challenge due to its unspecified nature. Coders must ensure thorough documentation to avoid misclassification.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should I document to support the use of C54.9?

Document all relevant clinical findings, including symptoms, imaging results, biopsy reports, and treatment plans. Ensure clarity regarding the unspecified nature of the malignancy.