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
Status post hysterectomy
Personal history of hysterectomy.
Acquired absence of uterus
Uterus absent due to surgical removal.
Endometrial disorders, unspecified
May be used for post-hysterectomy complications related to the endometrium if applicable.
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?
When to use each related code
Description |
---|
Status Post Hysterectomy |
Ovarian Failure Premature |
Surgical Menopause |
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.
Failing to code post-hysterectomy complications (e.g., hemorrhage, infection) alongside Z85.89 understates patient acuity and resource utilization, impacting quality metrics.
Incorrectly coding for oophorectomy (removal of ovaries) when only a hysterectomy was performed can result in overcoding and potential fraud investigations.
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.