History of Endometrial Cancer: ICD-10 Coding, Clinical Follow-Up, and Streamlined Documentation

Updated on: July 30, 2025

Endometrial cancer—the most common gynecologic malignancy in the U.S.—has a high survival rate when caught early. But for survivors, a personal history of endometrial cancer remains a critical piece of the medical narrative. Accurate documentation, appropriate follow-up care, and correct ICD-10 coding are essential for both clinical decision-making and administrative clarity.

In this article, we’ll cover:

• What constitutes a personal history of endometrial cancer

• When and how to use ICD-10 Z85.42

• Surveillance, recurrence risk, and clinical documentation best practices

• How DocScrib simplifies oncology documentation for providers

What Is Considered a “History of Endometrial Cancer”?

A personal history of endometrial cancer refers to a documented past diagnosis of cancer arising from the lining of the uterus, regardless of:

• Current disease status (remission or cured)

• Type of treatment received (surgery, radiation, chemo)

• Time elapsed since diagnosis

The patient is not currently undergoing active treatment, but the cancer history continues to influence:

• Surveillance plans

• Risk for recurrence or secondary cancers

• Medication selection (e.g., hormone replacement therapy contraindications)

• Fertility, surgical, and imaging considerations

ICD-10 Coding: Z85.42 – Personal History of Endometrial Cancer

The ICD-10 code Z85.42 should be used to represent a history of malignant neoplasm of endometrium. It falls under:

• Z85 – Personal history of malignant neoplasm

• Specifically: Z85.42 – Personal history of malignant neoplasm of other parts of uterus

When to Use Z85.42

✅ The patient had endometrial cancer in the past
✅ They are no longer undergoing active cancer treatment
✅ Surveillance or risk factor management is being addressed
✅ The cancer diagnosis may affect treatment or medication plans

⚠️ Do not use Z85.42 if the patient is still receiving chemotherapy, radiation, or other active treatment—use a C54.x code instead for current malignancy.

Related ICD-10 Codes

Clinical Importance of Documenting Endometrial Cancer History

Endometrial cancer survivors require long-term follow-up. Accurately documenting their cancer history allows clinicians to:

• Adjust care plans for potential recurrence or metastasis

• Avoid prescribing estrogen-based therapies

• Screen more proactively for secondary cancers (e.g., breast, colon)

• Coordinate surveillance imaging, especially in patients with Lynch syndrome

Sample Documentation Template

Subjective:

“Patient reports she was diagnosed with Stage IA endometrial adenocarcinoma 5 years ago. Underwent total abdominal hysterectomy and radiation. No recurrence. Currently asymptomatic.”

Objective:

No abdominal tenderness. No vaginal bleeding. Pelvic exam deferred. Recent PAP/HPV negative. No lymphadenopathy.

Assessment:

• History of endometrial cancer (Z85.42)

• Status: No evidence of disease

• No current treatment

• Risk category: Low/intermediate

Plan:

• Continue annual pelvic exams

• Avoid estrogen therapy

• Consider colonoscopy based on Lynch syndrome risk

• Code: Z85.42 + Z90.71 (if uterus removed)

Risk of Recurrence and Clinical Follow-Up

While endometrial cancer is often curable, recurrence does occur—typically within 3 years. Recurrence sites include the vaginal cuff, pelvic lymph nodes, or lungs.

Patients with History of Endometrial Cancer: Clinical Scenarios

Scenario 1: Post-Hysterectomy Surveillance

Use Z85.42 + Z90.71
Patient is disease-free, but surveillance is ongoing due to risk factors (e.g., obesity, hypertension, diabetes).

Scenario 2: Considering Hormone Replacement Therapy

Document Z85.42 to justify avoidance of estrogen, especially in patients with history of estrogen receptor-positive tumors.

Scenario 3: Lynch Syndrome or Family History

Consider adding Z80.41 – Family history of endometrial cancer or Z84.81 – Genetic susceptibility to neoplasm to guide cancer prevention efforts.

Why Accurate Coding and Documentation Matters

✅ Ensures appropriate surveillance and care coordination
✅ Triggers alerts for contraindicated treatments
✅ Supports accurate billing and audit readiness
✅ Protects against clinical oversight in medication planning
✅ Provides a complete longitudinal patient history

How DocScrib Streamlines Oncology Documentation

Capturing a history of endometrial cancer should be effortless—and with DocScrib, it is.

DocScrib Can Help Clinicians:

✅ Recognize and auto-suggest Z85.42 when a past cancer history is mentioned
✅ Automatically flag related codes like Z08, Z90.71, or Z79.899
✅ Generate templated follow-up notes for oncology and OB-GYN clinics
✅ Reduce documentation time by up to 70%
✅ Ensure coding compliance and complete problem list management

Experience AI-powered, oncology-aware documentation today.
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Quick ICD-10 Snapshot: History of Endometrial Cancer

FAQs

Q1: When is it appropriate to use Z85.42?
Use this code for any patient with a past diagnosis of endometrial cancer, who is not in active treatment, but whose history is relevant to their care.

Q2: Can I use Z85.42 along with Z90.71?
Yes. If the patient had a hysterectomy following cancer, Z90.71 helps document acquired absence of uterus.

Q3: How often should these patients be monitored?
Typically, low-risk patients are seen annually; high-risk patients may require visits every 3–6 months with imaging as needed.

Q4: Does DocScrib identify cancer history automatically?
Yes. DocScrib recognizes historical terms and flags relevant ICD-10 codes like Z85.42 and Z08 during live documentation.

Q5: Why does proper documentation matter post-cancer?
Beyond billing, it informs treatment decisions, screening frequency, and risk assessment for recurrence or secondary cancers.

Conclusion

A history of endometrial cancer should never be overlooked in clinical documentation. Whether it’s guiding surveillance, influencing medication decisions, or impacting OB-GYN care, correct use of ICD-10 Z85.42 helps clinicians provide accurate, informed, and coordinated care.

With AI-powered tools like DocScrib, documenting cancer history is smarter, faster, and more precise than ever before.

👉 Try DocScrib today – Book your free demo here