Two ICD-10-CM codes are typically needed for a total hysterectomy, covering uterus and cervix removal.

Two codes, not one: why a total hysterectomy often needs a second code

If you’ve ever wondered how to capture a total hysterectomy in ICD-10-CM coding, you’re not alone. The wording on the chart—the uterus removed, the cervix gone, maybe more—matters as much as the act itself. Getting this right isn’t about guessing. It’s about reflecting exactly what happened, so the medical record, billing, and health statistics tell the true story.

Let me break down what a total hysterectomy involves, and why most scenarios end up with two codes on the chart. The goal is clarity, not complication, so we’ll keep it practical and relatable.

What exactly is a total hysterectomy?

Think of a total hysterectomy as the surgical removal of the uterus plus the cervix. In plain language, the womb and the door to the inside of the uterus are removed. That’s the core procedure.

But real surgeries aren’t always that simple. In some cases, the surgeon also removes nearby structures—most commonly the ovaries and/or the fallopian tubes. When those extra removals happen, the chart needs to reflect them too. That’s where the coding question gets interesting: how many codes do you list?

Two codes are the typical answer, and here’s why.

Two codes: one for the main event, one for the adjacents

• The primary code describes the hysterectomy itself—the act of removing the uterus and cervix. This code captures the major surgical event.

• A second code is added if other reproductive organs were removed during the same operation, most often the ovaries (oophorectomy) and/or the fallopian tubes (salpingectomy). If both ovaries and tubes are taken out, there may be a single combined code for the adnexal removal, or separate codes for each component, depending on the coding system and documentation.

In practice, this means:

• If the patient has a total hysterectomy with only uterus and cervix removed, you’ll have the main hysterectomy code.

• If the ovaries and/or fallopian tubes are removed as well, you add a second code to describe those additional removals.

Documenting precisely matters. The operative report, surgeon’s notes, and pathology results all feed into the final code choice. A clear, well-documented chart avoids ambiguity and helps everyone from the coder to the biller to the health system’s statistics get it right.

A quick mental model you can use

Here’s a simple way to think about it:

• The first code = the big ticket item (the hysterectomy itself: uterus and cervix removed).

• The second code = any extra removals that happened during the same operation (ovaries, tubes, or other tissues).

If you’re ever uncertain, ask: “Was an additional organ removed beyond the uterus and cervix?” If the answer is yes, you’re likely adding a second code. If not, you might stick with a single code. The operative report usually leaves little room for guesswork here.

Real-world scenarios (with a human touch)

• Scenario A: Hysterectomy without adnexal removal

You’ve got a straightforward case: uterus and cervix removed, no ovaries or tubes touched. The chart should reflect the hysterectomy alone. Two codes? Not typically in this scenario. The primary hysterectomy code stands alone, and the record looks clean.

• Scenario B: Hysterectomy with oophorectomy

The surgeon removes the uterus, cervix, and both ovaries. Here, the total procedure gets two codes: one for the hysterectomy, one for the ovarian removal. Documentation confirms that both major steps occurred in the same operation, so the coding reflects that full scope.

• Scenario C: Hysterectomy with salpingectomy

If tubes are removed but ovaries are spared, you still have two codes: the hysterectomy and the salpingectomy. The chart makes clear what was taken out, and you respond with the corresponding codes for each component.

• Scenario D: Hysterectomy with adnexal removal, plus a nuance

Sometimes a surgeon removes the uterus, cervix, ovaries, and tubes, maybe even surrounding tissue. In that case, you’ll likely see multiple codes that map to each distinct removal, and you’ll follow the official coding guidelines to ensure that the sequence and grouping reflect the actual procedure arc.

Tips for accuracy in this area

• Read the operative report carefully. The surgeon’s notes are the primary guide. If the report lists “hysterectomy with bilateral salpingo-oophorectomy,” you’ll know two or more codes are warranted.

• Check what’s documented about the ovaries and tubes. If nothing is stated about removal of adnexa, assume the primary hysterectomy code is the main entry, unless another source clarifies otherwise.

• Don’t assume. When in doubt, seek clarification from the surgeon or the medical record team. A small note in the margins can save days of back-and-forth later.

• Align with guidelines. The ICD-10-CM/PCS guidance and local coding conventions will shape how you pair the codes and their order. When a second code is used, it typically reflects the additional removal(s) performed during the same surgical event.

• Use clear, specific language in your notes. If “adnexa removed” is documented, but not which parts, you may need to confirm whether ovaries, tubes, or both were taken out to select the exact codes.

Common pitfalls to avoid

• Assuming every hysterectomy gets a second code. The mere fact of removing the uterus and cervix doesn’t automatically imply adnexal removal. That second code should be grounded in documentation of additional organs being removed.

• Missing a second code when adnexal removal is documented. If the chart says ovaries were removed, a second code should be present. Leaving it out can understate the work done.

• Inconsistent coding across related records. If one department codes a hysterectomy with adnexal removal and another does not, it can cause billing and statistical discrepancies. Consistency matters.

• Not updating codes when the pathology report adds detail. Sometimes intraoperative findings differ from final pathology. If the final pathology confirms ovarian removal, that might affect the coding choice.

A few practical resources to keep handy

• ICD-10-CM Official Guidelines for Coding and Reporting. These guidelines help you understand how to interpret operative details, how to sequence codes, and when a second code is appropriate.

• The surgeon’s operative report and pathology notes. Documentation is your compass here.

• Your health system’s coding policy for hysterectomy cases. Local rules can influence code selection and sequencing.

• Coding clinics or similar professional references. They offer scenario-based guidance that can clarify edge cases.

Why this matters beyond the worksheet

Coding accuracy isn’t just about numbers on a page. It affects patient records, hospital reimbursement, and the public health picture. A properly coded hysterectomy that includes a second code when adnexa are removed provides a precise view of the patient’s surgical journey. It helps doctors track outcomes, supports proper billing, and contributes to reliable health statistics that inform care improvements.

A little bit of perspective

If coding feels like solving a tiny puzzle, you’re not far off. The pieces—procedure names, anatomy involved, and what the surgeon actually did—need to fit together without forcing a narrative. When they do, the record shines with clarity. And clarity, in turn, makes everything smoother: billing gets paid, audits go smoother, and future patients benefit from a transparent, well-documented history.

Bottom line, in simple terms

For a total hysterectomy, two codes are typically the standard answer in the scenarios many coders encounter: one for the hysterectomy itself and a second for any additional removal of reproductive organs like the ovaries or fallopian tubes. The exact need for a second code hinges on what the surgeon removes during the same operation, as documented in the operative report.

If you keep asking the right questions—what was removed, and was anything else taken out in the same surgical session?—you’ll land on the correct coding path more often than not. And that’s what makes the whole process feel a lot less puzzling and a lot more straightforward.

A final thought

Coding is part medical detective work, part record-keeping, and a good dose of careful reading. When you approach a total hysterectomy with that mindset, the two-code rule becomes less of a rule and more of a natural outcome your chart can support confidently. So next time you see a hysterectomy described in the notes, ask: were any adnexal tissues removed too? If the answer is yes, you’re already halfway to a precise, clean code set. And that—well—that’s the goal: accurate, meaningful coding that truly reflects what happened in the operating room.