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ICD-10 Guide
ICD-10 CodesC65.9

C65.9

Billable

Malignant neoplasm of unspecified renal pelvis

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

Code Description

ICD-10 C65.9 is a billable code used to indicate a diagnosis of malignant neoplasm of unspecified renal pelvis.

Key Diagnostic Point:

C65.9 refers to a malignant neoplasm located in the renal pelvis, which is the area of the kidney where urine collects before moving to the ureter. This type of cancer is part of the broader category of urinary tract malignancies, which can include cancers of the bladder, ureters, and kidneys. The renal pelvis is a less common site for malignancy compared to the bladder and renal parenchyma. Symptoms may include hematuria (blood in urine), flank pain, and urinary obstruction. Diagnosis typically involves imaging studies such as CT scans or MRIs, and confirmation is achieved through biopsy. Staging of renal pelvis cancer follows the TNM system, assessing tumor size (T), lymph node involvement (N), and metastasis (M). Treatment options may include surgical resection, such as nephroureterectomy, chemotherapy, and radiation therapy, depending on the stage and grade of the tumor. Accurate coding is essential for proper treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation quality regarding tumor location and staging.
  • Differentiation from other urinary tract malignancies.
  • Need for precise staging information for treatment planning.
  • Potential for misclassification if the specific site is not documented.

Audit Risk Factors

  • Inadequate documentation of tumor staging.
  • Failure to specify the exact location of the malignancy.
  • Misalignment between clinical findings and coded diagnosis.
  • Inconsistent use of imaging and biopsy results in documentation.

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed imaging reports, biopsy results, and surgical notes.

Common Clinical Scenarios

Diagnosis and management of renal pelvis tumors, staging evaluations, and surgical interventions.

Billing Considerations

Ensure clear documentation of tumor size, location, and any metastasis for accurate coding.

Oncology

Documentation Requirements

Pathology reports, treatment plans, and follow-up care notes.

Common Clinical Scenarios

Chemotherapy administration, radiation therapy planning, and post-operative care.

Billing Considerations

Documenting the response to treatment and any changes in staging is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use C65.9 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when the specific site of the malignancy is not documented
  • Include any relevant staging information and ensure that the diagnosis aligns with clinical findings

Exclusion Criteria

Do NOT use C65.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

50545CPT Code

Laparoscopic nephroureterectomy

Clinical Scenario

Used when a patient with C65.9 undergoes surgical resection of the affected kidney and ureter.

Documentation Requirements

Operative reports detailing the procedure and findings.

Specialty Considerations

Urology specialists must ensure accurate documentation of tumor characteristics.

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. C65.9 provides a clear designation for unspecified renal pelvis malignancies, which aids in treatment planning.

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. C65.9 provides a clear designation for unspecified renal pelvis malignancies, which aids in treatment planning.

Reimbursement & Billing Impact

reimbursement processes. C65.9 provides a clear designation for unspecified renal pelvis malignancies, which aids in treatment planning.

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 significance of coding C65.9?

Coding C65.9 is crucial for accurately representing a patient's diagnosis of malignant neoplasm in the renal pelvis, which impacts treatment decisions and reimbursement.