Find information on documenting and coding a personal history of endometrial cancer. Learn about relevant ICD-10 codes, Z85.820 and Z87.411, for personal history of malignant neoplasm of the body of the uterus and family history of endometrial cancer, respectively. This resource covers clinical documentation best practices, healthcare guidelines, and medical coding accuracy for a past diagnosis of endometrial cancer. Explore the importance of precise medical records for patients with a history of uterine cancer and related gynecological malignancies.
Also known as
Personal history of malignant neoplasm of body of uterus
Indicates prior endometrial cancer diagnosis, now inactive or resolved.
Personal history of malignant neoplasm
Covers history of various cancers, including gynecological malignancies.
Factors influencing health status and contact with health services
Includes personal history codes for various conditions, including cancer.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the endometrial cancer currently active?
When to use each related code
| Description |
|---|
| Personal history of endometrial cancer |
| History of uterine cancer NOS |
| Personal history of ovarian cancer |
Incorrectly assigning Z85.821 when active cancer (C54.1) exists. Use only for past, successfully treated endometrial cancer.
Lack of specificity using Z85.821 without clear documentation of morphology or treatment. Impacts quality reporting and reimbursement.
Coding Z85.821 based solely on patient-reported history without provider validation in medical record. Requires physician confirmation.
Patient presents with a personal history of endometrial cancer (endometrial carcinoma, uterine cancer). Initial diagnosis date was [Date of Diagnosis]. The primary site was [Location of Primary Tumor, e.g., endometrium, uterus] and the histologic type was [Histology, e.g., endometrioid adenocarcinoma, serous carcinoma]. The stage at diagnosis was [Stage, e.g., IA, IIB] according to the [Staging System, e.g., FIGO, AJCC] staging system. Initial treatment consisted of [Treatment details, e.g., total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, followed by adjuvant chemotherapy with carboplatin and paclitaxel]. Patient reports [Symptoms, e.g., being asymptomatic, experiencing vaginal bleeding, pelvic pain]. Current surveillance includes [Surveillance plan, e.g., physical examination, CA-125 levels, pelvic ultrasound] every [Frequency, e.g., 3 months, 6 months]. Assessment includes ongoing monitoring for recurrence of endometrial cancer. Plan includes continued surveillance per established guidelines and management of any recurrent or persistent symptoms. Differential diagnoses at the time of initial diagnosis included [Differential Diagnoses, e.g., atypical endometrial hyperplasia, uterine fibroids, endometrial polyps]. Relevant medical history includes [Relevant medical history, e.g., history of obesity, hypertension, diabetes, use of tamoxifen]. Family history is significant for [Family history, e.g., breast cancer, ovarian cancer, Lynch syndrome]. Patient education provided regarding signs and symptoms of recurrence, importance of follow-up appointments, and healthy lifestyle modifications.