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v1.0.0
ICD-10 Guide
ICD-10 CodesD09.9

D09.9

Billable

Carcinoma in situ, unspecified

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

Code Description

ICD-10 D09.9 is a billable code used to indicate a diagnosis of carcinoma in situ, unspecified.

Key Diagnostic Point:

Carcinoma in situ (CIS) refers to a group of abnormal cells that remain localized and have not invaded surrounding tissues. The term 'unspecified' indicates that the specific site of the carcinoma is not documented or is not clearly defined. CIS can occur in various organs, including the breast, cervix, skin, and bladder. It is considered a precancerous condition, meaning that while the cells are not yet invasive, there is a potential risk for progression to invasive cancer if left untreated. Surveillance protocols for patients diagnosed with CIS typically involve regular monitoring through imaging studies, biopsies, and clinical examinations to detect any changes in the cellular structure or behavior. The risk of progression varies depending on the site of the carcinoma, the patient's age, and other risk factors such as family history and lifestyle choices. Early detection and intervention are crucial in managing CIS to prevent the development of invasive cancer.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of carcinoma sites
  • Need for precise clinical terminology
  • Differentiation from other neoplastic conditions
  • Potential for progression to invasive cancer

Audit Risk Factors

  • Insufficient documentation of the carcinoma site
  • Lack of follow-up notes or surveillance results
  • Inconsistent terminology used in clinical notes
  • Failure to document risk factors for progression

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans must be documented.

Common Clinical Scenarios

Patients undergoing surveillance for CIS after initial diagnosis, treatment planning discussions.

Billing Considerations

Ensure that all findings from biopsies and imaging are clearly documented to support the diagnosis.

Dermatology

Documentation Requirements

Photographic evidence of lesions, detailed descriptions of skin findings.

Common Clinical Scenarios

Monitoring of skin lesions diagnosed as CIS, treatment with topical agents or surgical excision.

Billing Considerations

Document the size, location, and characteristics of lesions to support coding.

Coding Guidelines

Inclusion Criteria

Use D09.9 When
  • According to ICD
  • CM guidelines, D09
  • 9 should be used when the specific site of carcinoma in situ is not documented
  • Coders should ensure that the diagnosis is confirmed by pathology and that the documentation supports the diagnosis of carcinoma in situ

Exclusion Criteria

Do NOT use D09.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

88305CPT Code

Pathology examination, surgical

Clinical Scenario

Used when a biopsy is performed to confirm carcinoma in situ.

Documentation Requirements

Pathology report must be included in the patient's medical record.

Specialty Considerations

Oncologists should ensure that the pathology report clearly states the diagnosis.

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 data accuracy and patient care tracking. D09.9 serves as a catch-all for unspecified cases, but coders must ensure that documentation is thorough to avoid misclassification.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving data accuracy and patient care tracking. D09.9 serves as a catch-all for unspecified cases, but coders must ensure that documentation is thorough to avoid misclassification.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving data accuracy and patient care tracking. D09.9 serves as a catch-all for unspecified cases, but coders must ensure that documentation is thorough to avoid misclassification.

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 does carcinoma in situ mean?

Carcinoma in situ refers to abnormal cells that are localized and have not invaded surrounding tissues. It is considered a precancerous condition.

How is carcinoma in situ monitored?

Patients with carcinoma in situ are typically monitored through regular imaging studies, biopsies, and clinical examinations to detect any changes.