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v1.0.0
ICD-10 Guide
ICD-10 CodesChapter 2: NeoplasmsC54

C54

Billable

Malignant neoplasm of corpus uteri

Chapter 2:Neoplasms

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

Code Description

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

Key Diagnostic Point:

C54 refers to malignant neoplasms located in the corpus uteri, which is the main body of the uterus. This condition is often associated with endometrial cancer, the most common type of uterine cancer. Risk factors include obesity, diabetes, hypertension, and a history of unopposed estrogen exposure. Symptoms may include abnormal vaginal bleeding, pelvic pain, and changes in menstrual patterns. Diagnosis typically involves imaging studies, endometrial biopsy, and histopathological examination. Staging of the disease is crucial for treatment planning and is based on the FIGO (International Federation of Gynecology and Obstetrics) system, which considers tumor size, depth of invasion, lymph node involvement, and distant metastasis. CA-125, a tumor marker, may be elevated in cases of endometrial cancer and is often used in conjunction with imaging and biopsy results to assess disease progression or recurrence. Treatment options may include surgery, radiation therapy, and chemotherapy, depending on the stage and grade of the tumor.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of staging systems (FIGO, AJCC) that may be used
  • Need for precise documentation of tumor size and spread
  • Differentiation between types of uterine malignancies
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of staging and tumor characteristics
  • Misclassification of tumor type or grade
  • Failure to document co-existing conditions
  • Inconsistent use of CA-125 levels in treatment planning

Specialty Focus

Medical Specialties

Gynecologic Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans must be documented.

Common Clinical Scenarios

Diagnosis and treatment of endometrial cancer, management of recurrent disease, and pre-operative assessments.

Billing Considerations

Accurate staging and grading of tumors are critical for appropriate coding and treatment planning.

Radiology

Documentation Requirements

Clear imaging reports indicating tumor size, location, and any metastasis.

Common Clinical Scenarios

Imaging for staging and follow-up of uterine malignancies.

Billing Considerations

Radiologists must ensure that imaging findings correlate with clinical documentation for accurate coding.

Coding Guidelines

Inclusion Criteria

Use C54 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, staging, and any associated conditions
  • Include specific details about the tumor's characteristics and treatment plan

Exclusion Criteria

Do NOT use C54 When
No specific exclusions found.

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed for treatment of endometrial cancer.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Gynecologic oncologists must document tumor characteristics and staging.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of uterine malignancies, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of uterine malignancies, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    American Cancer Society - Endometrial Cancer

Coding & Billing References

  • •
    American Cancer Society - Endometrial Cancer

Frequently Asked Questions

What is the primary treatment for C54?

The primary treatment for malignant neoplasm of the corpus uteri typically involves surgical intervention, such as a hysterectomy, often followed by radiation or chemotherapy depending on the stage and grade of the cancer.