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ICD-10 Guide
ICD-10 CodesD09.10

D09.10

Billable

Carcinoma in situ of unspecified urinary organ

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

Code Description

ICD-10 D09.10 is a billable code used to indicate a diagnosis of carcinoma in situ of unspecified urinary organ.

Key Diagnostic Point:

Carcinoma in situ (CIS) of the urinary system refers to a localized cancer that has not invaded surrounding tissues. This condition is characterized by abnormal cells that are confined to the epithelial layer of the urinary organ, which may include the bladder, ureters, or urethra. The term 'unspecified' indicates that the exact location of the carcinoma has not been determined or documented. CIS is often asymptomatic in its early stages, making early detection challenging. Surveillance protocols typically involve regular cystoscopy and urine cytology to monitor for progression to invasive cancer. The risk of progression varies depending on factors such as the patient's age, the presence of dysplasia, and the specific characteristics of the carcinoma. Patients diagnosed with CIS require careful management and follow-up to prevent the development of invasive disease, which can significantly impact treatment options and outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified location can lead to ambiguity in documentation.
  • Requires thorough understanding of carcinoma in situ versus invasive cancer.
  • Potential for misclassification if not properly documented.
  • Need for regular surveillance and follow-up coding.

Audit Risk Factors

  • Inadequate documentation of the carcinoma's location.
  • Failure to document surveillance protocols.
  • Misinterpretation of biopsy results.
  • Inconsistent follow-up records.

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans.

Common Clinical Scenarios

Diagnosis of CIS during routine screening, management of bladder CIS, and follow-up after treatment.

Billing Considerations

Ensure clear documentation of the urinary organ involved and any treatment interventions.

Oncology

Documentation Requirements

Comprehensive cancer staging, treatment response assessments, and follow-up care plans.

Common Clinical Scenarios

Management of patients with CIS transitioning to invasive cancer, and coordination of multidisciplinary care.

Billing Considerations

Accurate documentation of tumor characteristics and patient history is crucial for treatment planning.

Coding Guidelines

Inclusion Criteria

Use D09.10 When
  • According to ICD
  • 10 coding guidelines, D09
  • 10 should be used when the carcinoma is confirmed as in situ and the specific urinary organ is not documented
  • Coders should ensure that the diagnosis is supported by pathology reports and clinical findings

Exclusion Criteria

Do NOT use D09.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

52000CPT Code

Cystoscopy, diagnostic

Clinical Scenario

Used for initial diagnosis and surveillance of CIS.

Documentation Requirements

Document indication for cystoscopy and findings.

Specialty Considerations

Urologists should ensure accurate reporting of findings and any interventions performed.

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 cancer registries and treatment planning. D09.10 provides a means to capture cases where the specific urinary organ is not documented, although it may lead to increased scrutiny during audits.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the accuracy of cancer registries and treatment planning. D09.10 provides a means to capture cases where the specific urinary organ is not documented, although it may lead to increased scrutiny during audits.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the accuracy of cancer registries and treatment planning. D09.10 provides a means to capture cases where the specific urinary organ is not documented, although it may lead to increased scrutiny during audits.

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 carcinoma in situ?

Carcinoma in situ is a localized form of cancer where abnormal cells are present but have not invaded surrounding tissues. It is often asymptomatic and requires careful monitoring.