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ICD-10 Guide
ICD-10 CodesC65.1

C65.1

Billable

Malignant neoplasm of right renal pelvis

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

Code Description

ICD-10 C65.1 is a billable code used to indicate a diagnosis of malignant neoplasm of right renal pelvis.

Key Diagnostic Point:

C65.1 refers to a malignant neoplasm located in the right renal pelvis, which is the area of the kidney where urine collects before moving to the ureter. This type of cancer is classified under urinary tract malignancies and is often associated with risk factors such as smoking, exposure to certain chemicals, and chronic irritation or inflammation of the urinary tract. Symptoms may include hematuria (blood in urine), flank pain, and urinary obstruction. Diagnosis typically involves imaging studies such as CT scans or MRIs, along with cystoscopy and biopsy for definitive histological confirmation. Staging of renal pelvis cancer is crucial for determining the extent of disease and guiding treatment options, which may include surgical resection, chemotherapy, or radiation therapy. Surgical management often involves nephroureterectomy, where the affected kidney and ureter are removed, and may also include lymph node dissection if metastasis is suspected. The prognosis varies based on the stage at diagnosis, with early-stage cancers having a better outcome compared to advanced stages.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between renal pelvis and other urinary tract malignancies
  • Staging complexity due to varying degrees of local invasion and metastasis
  • Need for precise documentation of tumor size and location
  • Potential for co-existing conditions affecting treatment and coding

Audit Risk Factors

  • Inadequate documentation of staging and tumor characteristics
  • Failure to document co-existing conditions that may affect treatment
  • Misclassification of tumor location (right vs. left)
  • Inconsistent coding of surgical procedures performed

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed pathology reports, imaging studies, and surgical notes are essential for accurate coding.

Common Clinical Scenarios

Diagnosis and management of renal pelvis tumors, pre-operative assessments, and post-operative follow-ups.

Billing Considerations

Urologists must ensure clear documentation of tumor staging and any associated urinary tract anomalies.

Oncology

Documentation Requirements

Comprehensive treatment plans, chemotherapy regimens, and response assessments are crucial.

Common Clinical Scenarios

Management of advanced renal pelvis cancer, including systemic therapy and palliative care.

Billing Considerations

Oncologists should document the rationale for treatment choices and any clinical trials involved.

Coding Guidelines

Inclusion Criteria

Use C65.1 When
  • According to ICD
  • 10 guidelines, C65
  • 1 should be used when the malignant neoplasm is confirmed by histology and located specifically in the right renal pelvis

Exclusion Criteria

Do NOT use C65.1 When
  • Exclusion criteria include benign tumors or neoplasms located in other parts of the urinary tract

Related ICD-10 Codes

Related CPT Codes

50590CPT Code

Laparoscopic nephrectomy

Clinical Scenario

Used for surgical management of renal pelvis tumors.

Documentation Requirements

Operative reports detailing the procedure and findings.

Specialty Considerations

Urologists should document the extent of resection and any complications.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urinary tract malignancies, improving the accuracy of data collection and reimbursement processes. C65.1 provides a clear distinction for malignant neoplasms of the right renal pelvis, which aids in treatment planning and epidemiological studies.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urinary tract malignancies, improving the accuracy of data collection and reimbursement processes. C65.1 provides a clear distinction for malignant neoplasms of the right renal pelvis, which aids in treatment planning and epidemiological studies.

Reimbursement & Billing Impact

reimbursement processes. C65.1 provides a clear distinction for malignant neoplasms of the right renal pelvis, which aids in treatment planning and epidemiological studies.

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 is the primary treatment for malignant neoplasm of the right renal pelvis?

The primary treatment is often surgical resection, typically a nephroureterectomy, depending on the stage and extent of the disease.