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v1.0.0
ICD-10 Guide
ICD-10 CodesC38.2

C38.2

Billable

Malignant neoplasm of posterior mediastinum

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 C38.2 is a billable code used to indicate a diagnosis of malignant neoplasm of posterior mediastinum.

Key Diagnostic Point:

Malignant neoplasm of the posterior mediastinum refers to cancerous tumors located in the area of the thorax behind the heart and between the lungs. This region can harbor various types of malignancies, including lymphomas, neurogenic tumors, and germ cell tumors. The posterior mediastinum is less commonly affected than the anterior and middle mediastinum, but when it is, it often presents with symptoms such as chest pain, cough, dyspnea, or systemic symptoms like weight loss and fever. Diagnosis typically involves imaging studies such as CT or MRI scans, followed by biopsy for histological confirmation. Treatment options may include surgical resection, chemotherapy, and radiation therapy, depending on the tumor type and stage. Surgical considerations are critical, as the proximity to vital structures such as the aorta, esophagus, and spinal cord can complicate resection efforts. Accurate coding for this condition is essential for proper treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of tumor types that can occur in the posterior mediastinum
  • Need for precise documentation of tumor type and stage
  • Potential for overlapping symptoms with other thoracic conditions
  • Variability in treatment approaches based on tumor histology

Audit Risk Factors

  • Inadequate documentation of tumor type and histology
  • Failure to document staging of the malignancy
  • Misclassification of tumor location
  • Lack of clarity in treatment plans and outcomes

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans must be documented.

Common Clinical Scenarios

Diagnosis and management of lymphoma or neurogenic tumors in the posterior mediastinum.

Billing Considerations

Ensure accurate coding of tumor type and staging to reflect treatment decisions.

Thoracic Surgery

Documentation Requirements

Operative reports detailing surgical approach and findings are essential.

Common Clinical Scenarios

Surgical resection of posterior mediastinal tumors.

Billing Considerations

Document any complications or anatomical challenges encountered during surgery.

Coding Guidelines

Inclusion Criteria

Use C38.2 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the tumor's location, type, and stage
  • Include any relevant co
  • morbidities that may affect treatment

Exclusion Criteria

Do NOT use C38.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

32480CPT Code

Thoracotomy, with excision of tumor

Clinical Scenario

Used when a malignant neoplasm in the posterior mediastinum is surgically resected.

Documentation Requirements

Operative report detailing the tumor's location and size.

Specialty Considerations

Thoracic surgeons should document any complications or anatomical challenges.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of malignancies, including those in the posterior mediastinum, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of malignancies, including those in the posterior mediastinum, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common types of tumors found in the posterior mediastinum?

Common types include lymphomas, neurogenic tumors, and germ cell tumors. Each type has distinct characteristics and treatment protocols.

How is a malignant neoplasm of the posterior mediastinum diagnosed?

Diagnosis typically involves imaging studies such as CT or MRI, followed by biopsy for histological confirmation.