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Z90.712
ICD-10-CM
Status Post Hysterectomy

Find comprehensive information on Status Post Hysterectomy diagnosis, including clinical documentation tips, medical coding guidelines (ICD-10 Z90.81), postoperative care, and long-term health management. Learn about common symptoms, potential complications, and best practices for healthcare professionals involved in the care of patients after a hysterectomy. This resource covers essential aspects of post-hysterectomy care, from initial recovery to ongoing health monitoring.

Also known as

S/P Hysterectomy
Post-Hysterectomy Status

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z90.712 Coding
Z85.4

Status post hysterectomy

Personal history of hysterectomy.

Z90.7

Acquired absence of uterus

Uterus absent due to surgical removal.

N85.9

Endometrial disorders, unspecified

May be used for post-hysterectomy complications related to the endometrium if applicable.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is there a complication currently being addressed?

  • Yes

    What is the complication?

  • No

    Is status post status required for another condition?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Status Post Hysterectomy
Ovarian Failure Premature
Surgical Menopause

Documentation Best Practices

Documentation Checklist
  • Hysterectomy type (total/partial, abdominal/vaginal/laparoscopic)
  • Surgical approach details (robotic, open, minimally invasive)
  • Indication for hysterectomy (fibroids, endometriosis, cancer)
  • Post-op complications (infection, hemorrhage, pain)
  • Current symptoms and status (hormone levels, recovery progress)

Coding and Audit Risks

Common Risks
  • Unspecified Hysterectomy

    Coding Z85.89 (Personal history of other specified diseases) without specifying the type of hysterectomy (e.g., total, subtotal, radical) may lead to inaccurate DRG assignment and reimbursement.

  • Post-op Complication Coding

    Failing to code post-hysterectomy complications (e.g., hemorrhage, infection) alongside Z85.89 understates patient acuity and resource utilization, impacting quality metrics.

  • Unnecessary Oophorectomy Coding

    Incorrectly coding for oophorectomy (removal of ovaries) when only a hysterectomy was performed can result in overcoding and potential fraud investigations.

Mitigation Tips

Best Practices
  • Code Z85.818 for status post hysterectomy, not N45.9.
  • Document type of hysterectomy (abdominal, vaginal, laparoscopic).
  • Specify reason for hysterectomy in documentation for accurate coding.
  • For complications, code the complication, not just Z85.818.
  • Query physician if hysterectomy type/reason is unclear in record.

Clinical Decision Support

Checklist
  • Confirm hysterectomy type (partial/total/radical)
  • Verify date of procedure in operative report
  • Check for documented complications (infection/hemorrhage)
  • Review pathology report for benign/malignant findings

Reimbursement and Quality Metrics

Impact Summary
  • Status Post Hysterectomy reimbursement hinges on accurate ICD-10-CM coding (Z90.7), impacting DRG assignment and payment.
  • Coding quality affects Case Mix Index (CMI) accuracy, influencing hospital reimbursement and quality reporting.
  • Precise POA indicator reporting for Status Post Hysterectomy is crucial for proper MS-DRG assignment and payment.
  • Documentation specificity impacts severity level, influencing hospital reimbursement for Status Post Hysterectomy complications.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code Z88.0 for routine post-hysterectomy
  • Look for complications, code additionally
  • Specify type of hysterectomy (e.g., abdominal, vaginal)
  • Document surgical approach and findings
  • For long-term sequelae, code N99.8

Documentation Templates

Patient presents status post hysterectomy.  The procedure date was documented as [Date of Procedure]. The indication for the hysterectomy was [Indication, e.g., uterine fibroids, menorrhagia, endometrial hyperplasia, uterine prolapse, cervical dysplasia, endometrial cancer, etc.].  The surgical approach was [Surgical approach, e.g., total abdominal hysterectomy, laparoscopic hysterectomy, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy, robotic-assisted hysterectomy].  Ovaries were [Status of ovaries, e.g., conserved, removed].  Fallopian tubes were [Status of fallopian tubes, e.g., conserved, removed].  Surgical report reviewed and confirms the operative findings.  Current post-operative course is [Description of post-operative course, e.g., uncomplicated, complicated by infection, hemorrhage, etc.]. Patient reports [Patient-reported symptoms, e.g., no vaginal bleeding, minimal abdominal discomfort, manageable pain controlled with prescribed medications].  Physical exam reveals [Physical exam findings, e.g., abdominal incision well-healing, no vaginal discharge, normal bowel sounds].  Plan includes [Plan, e.g., continue current pain management regimen, follow-up appointment scheduled in [Duration], patient education provided on post-hysterectomy care and potential complications, encourage gradual return to normal activity as tolerated].  Patient understands and agrees with the plan.
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