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v1.0.0
ICD-10 Guide
ICD-10 CodesD09.0

D09.0

Billable

Carcinoma in situ of bladder

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

Code Description

ICD-10 D09.0 is a billable code used to indicate a diagnosis of carcinoma in situ of bladder.

Key Diagnostic Point:

Carcinoma in situ (CIS) of the bladder is a non-invasive form of bladder cancer characterized by abnormal cells that have not yet invaded deeper tissues. It is often detected through cystoscopy and biopsy, where the presence of atypical cells is confirmed. Patients with CIS may present with symptoms such as hematuria (blood in urine), urinary frequency, and urgency. The condition is considered a precursor to invasive bladder cancer, necessitating close surveillance and management. Treatment options may include intravesical therapy, such as Bacillus Calmette-Guérin (BCG) therapy, or surgical intervention. Regular follow-up with cystoscopy is crucial to monitor for progression to invasive disease, as the risk of progression is significant, particularly in high-grade cases. The prognosis for patients with CIS can vary based on factors such as tumor grade, response to treatment, and the presence of concurrent bladder lesions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation between carcinoma in situ and invasive bladder cancer
  • Need for precise documentation of biopsy results
  • Variability in treatment protocols and follow-up care
  • Potential for progression to invasive disease requiring different coding

Audit Risk Factors

  • Inadequate documentation of biopsy results
  • Failure to document follow-up cystoscopy findings
  • Misclassification of invasive versus non-invasive disease
  • Omission of associated symptoms in medical records

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed pathology reports, treatment plans, and follow-up notes are essential.

Common Clinical Scenarios

Diagnosis of CIS during routine cystoscopy, management of recurrent CIS, and treatment response evaluation.

Billing Considerations

Urologists must ensure accurate staging and grading of tumors to guide treatment and follow-up.

Oncology

Documentation Requirements

Comprehensive treatment records, including chemotherapy or immunotherapy details.

Common Clinical Scenarios

Management of patients receiving BCG therapy and monitoring for side effects.

Billing Considerations

Oncologists should document the rationale for treatment choices and patient responses.

Coding Guidelines

Inclusion Criteria

Use D09.0 When
  • According to ICD
  • 10 guidelines, D09
  • 0 should be used when documenting carcinoma in situ specifically of the bladder
  • It is important to ensure that the diagnosis is confirmed through biopsy and that the documentation reflects the non
  • invasive nature of the condition

Exclusion Criteria

Do NOT use D09.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

52224CPT Code

Cystourethroscopy with biopsy

Clinical Scenario

Used for diagnosis of CIS during evaluation of hematuria.

Documentation Requirements

Pathology report confirming CIS and details of the cystoscopy.

Specialty Considerations

Urologists must document the findings and any treatment decisions made during the procedure.

51798CPT Code

Intravesical instillation of chemotherapy

Clinical Scenario

Used for administering BCG therapy for CIS.

Documentation Requirements

Record of treatment administration and patient response.

Specialty Considerations

Oncologists should document the rationale for treatment and any side effects experienced by the patient.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the accuracy of data collection and treatment tracking. D09.0 provides a clear distinction from invasive cancers, which is crucial for treatment planning and surveillance.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the accuracy of data collection and treatment tracking. D09.0 provides a clear distinction from invasive cancers, which is crucial for treatment planning and surveillance.

Reimbursement & Billing Impact

reimbursement and to avoid denials.

Resources

Clinical References

  • •
    American Urological Association Guidelines
  • •
    National Comprehensive Cancer Network Guidelines

Coding & Billing References

  • •
    American Urological Association Guidelines
  • •
    National Comprehensive Cancer Network Guidelines

Frequently Asked Questions

What is the difference between carcinoma in situ and invasive bladder cancer?

Carcinoma in situ is a non-invasive form of cancer where abnormal cells are present but have not invaded surrounding tissues. Invasive bladder cancer, on the other hand, has penetrated deeper layers of the bladder wall and may spread to other parts of the body.

How often should patients with D09.0 be monitored?

Patients diagnosed with carcinoma in situ of the bladder typically require cystoscopic surveillance every 3 to 6 months for the first 2 years, then annually if no recurrence is detected.