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ICD-10 Guide
ICD-10 CodesD09.21

D09.21

Billable

Carcinoma in situ of right eye

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

Code Description

ICD-10 D09.21 is a billable code used to indicate a diagnosis of carcinoma in situ of right eye.

Key Diagnostic Point:

Carcinoma in situ (CIS) of the right eye refers to a localized, non-invasive form of cancer that is confined to the epithelial layer of the eye. This condition is characterized by abnormal cell growth that has not yet invaded surrounding tissues. The right eye may be affected by various types of carcinoma in situ, including squamous cell carcinoma and basal cell carcinoma. Diagnosis typically involves a thorough examination, including imaging studies and possibly a biopsy to confirm the presence of atypical cells. Surveillance protocols for patients diagnosed with carcinoma in situ of the right eye often include regular ophthalmologic evaluations to monitor for any signs of progression or invasion. The risk of progression to invasive cancer varies based on factors such as the type of carcinoma, the patient's overall health, and the adequacy of treatment. Early detection and intervention are crucial to prevent the development of invasive cancer, making ongoing surveillance essential for affected individuals.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of carcinoma in situ
  • Need for precise documentation of the location and type of carcinoma
  • Potential for progression to invasive cancer requiring different coding
  • Variability in treatment protocols and follow-up care

Audit Risk Factors

  • Inadequate documentation of the diagnosis and treatment plan
  • Failure to document follow-up care and surveillance
  • Misclassification of the type of carcinoma
  • Lack of interdisciplinary communication in documentation

Specialty Focus

Medical Specialties

Ophthalmology

Documentation Requirements

Detailed clinical notes including examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Routine surveillance visits, treatment planning for carcinoma in situ, and post-treatment follow-ups.

Billing Considerations

Ensure clear documentation of the type of carcinoma and any changes in the patient's condition.

Oncology

Documentation Requirements

Comprehensive treatment records, including chemotherapy or radiation therapy details if applicable.

Common Clinical Scenarios

Consultations for treatment options, management of side effects, and coordination of care.

Billing Considerations

Document any interdisciplinary treatment plans and patient education provided.

Coding Guidelines

Inclusion Criteria

Use D09.21 When
  • According to the official coding guidelines, carcinoma in situ is classified under specific categories based on the site and type of cancer
  • It is essential to use the most specific code available and to document the diagnosis accurately

Exclusion Criteria

Do NOT use D09.21 When
  • Exclusion criteria include any invasive forms of cancer, which would require different coding

Related ICD-10 Codes

Related CPT Codes

67800CPT Code

Excision, eyelid lesion

Clinical Scenario

Used when a patient with carcinoma in situ undergoes surgical excision of the lesion.

Documentation Requirements

Document the size, location, and type of lesion excised.

Specialty Considerations

Ophthalmology should ensure that the excision is documented in the context of the carcinoma in situ.

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. This specificity aids in better patient management and resource allocation.

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. This specificity aids in better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the accuracy of data collection and treatment tracking. This specificity aids in better patient management and resource allocation.

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 carcinoma in situ of the right eye?

Carcinoma in situ of the right eye is significant as it indicates a localized cancer that has not invaded surrounding tissues. Early detection and treatment are crucial to prevent progression to invasive cancer.