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v1.0.0
ICD-10 Guide
ICD-10 CodesC48.0

C48.0

Billable

Malignant neoplasm of retroperitoneum

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

Code Description

ICD-10 C48.0 is a billable code used to indicate a diagnosis of malignant neoplasm of retroperitoneum.

Key Diagnostic Point:

C48.0 refers to malignant neoplasms located in the retroperitoneum, which is the anatomical space behind the peritoneum that contains the kidneys, ureters, aorta, inferior vena cava, and other structures. The retroperitoneum is a common site for soft tissue sarcomas, which are malignant tumors arising from connective tissues such as fat, muscle, nerves, and blood vessels. These tumors can be aggressive and may present with vague symptoms, often leading to late diagnosis. Grading of soft tissue sarcomas is crucial, as it determines the tumor's aggressiveness and guides treatment decisions. The management of retroperitoneal sarcomas typically involves a multidisciplinary approach, including surgical resection, chemotherapy, and radiation therapy, depending on the tumor's size, grade, and location. Accurate coding for C48.0 requires comprehensive documentation of the tumor's characteristics, treatment plan, and any associated complications, as these factors significantly influence patient outcomes and coding accuracy.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variability in tumor types and histology
  • Need for precise documentation of tumor grade and size
  • Multidisciplinary treatment approaches
  • Potential for metastasis and staging considerations

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to capture the multidisciplinary treatment approach
  • Misclassification of tumor grade
  • Inaccurate staging of the neoplasm

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans.

Common Clinical Scenarios

Diagnosis and management of soft tissue sarcomas, treatment planning, and follow-up care.

Billing Considerations

Ensure accurate coding of tumor grade and staging, as these impact treatment decisions.

Surgery

Documentation Requirements

Operative reports detailing surgical resection and any complications.

Common Clinical Scenarios

Surgical intervention for tumor resection and management of surgical complications.

Billing Considerations

Document the extent of resection and any adjuvant therapies planned.

Coding Guidelines

Inclusion Criteria

Use C48.0 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the tumor's location, size, and grade
  • Include any relevant treatment details and comorbid conditions that may affect management

Exclusion Criteria

Do NOT use C48.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

38500CPT Code

Biopsy of lymph nodes

Clinical Scenario

Used when lymph nodes are sampled for staging of retroperitoneal sarcoma.

Documentation Requirements

Document the reason for biopsy and findings.

Specialty Considerations

Oncology specialists should ensure accurate staging is reflected in the documentation.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of malignant neoplasms, improving the accuracy of data collection and reimbursement processes. C48.0 provides a clear classification for retroperitoneal sarcomas, facilitating better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of malignant neoplasms, improving the accuracy of data collection and reimbursement processes. C48.0 provides a clear classification for retroperitoneal sarcomas, facilitating better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

reimbursement processes. C48.0 provides a clear classification for retroperitoneal sarcomas, facilitating better tracking of treatment outcomes and resource allocation.

Resources

Clinical References

  • •
    American Cancer Society - Sarcoma

Coding & Billing References

  • •
    American Cancer Society - Sarcoma

Frequently Asked Questions

What is the significance of tumor grading in C48.0?

Tumor grading is crucial as it indicates the aggressiveness of the cancer and influences treatment decisions. High-grade tumors may require more aggressive treatment compared to low-grade tumors.