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ICD-10 Guide
ICD-10 CodesD11.9

D11.9

Billable

Benign neoplasm of major salivary gland, unspecified

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

Code Description

ICD-10 D11.9 is a billable code used to indicate a diagnosis of benign neoplasm of major salivary gland, unspecified.

Key Diagnostic Point:

Benign neoplasms of the major salivary glands, such as the parotid, submandibular, and sublingual glands, are non-cancerous growths that can arise from various cell types within these glands. These neoplasms may present as asymptomatic masses or cause symptoms such as swelling, pain, or discomfort depending on their size and location. Common types of benign salivary gland tumors include pleomorphic adenomas, Warthin tumors, and oncocytomas. While these tumors are generally not life-threatening, they require careful evaluation to rule out malignant transformation, especially in older patients or those with a history of radiation exposure. Surveillance is crucial, as some benign tumors can exhibit growth over time, necessitating periodic imaging or clinical assessment. The unspecified nature of this code indicates that the specific type of benign neoplasm has not been documented, which may complicate treatment planning and follow-up. Accurate coding is essential for appropriate management and resource allocation in healthcare settings.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified nature of the neoplasm can lead to ambiguity in treatment.
  • Differentiation from malignant neoplasms requires thorough documentation.
  • Potential for growth necessitates ongoing surveillance and follow-up coding.
  • Variability in clinical presentation may complicate accurate coding.

Audit Risk Factors

  • Inadequate documentation of the tumor's benign nature.
  • Failure to document the size and location of the neoplasm.
  • Lack of follow-up notes or imaging results.
  • Misclassification as malignant due to insufficient detail.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed clinical notes including tumor size, location, and symptoms.

Common Clinical Scenarios

Evaluation of a patient presenting with a salivary gland mass.

Billing Considerations

Ensure clear differentiation from malignant conditions and document any imaging findings.

Pathology

Documentation Requirements

Histopathological reports confirming benign nature.

Common Clinical Scenarios

Review of biopsy specimens from salivary gland lesions.

Billing Considerations

Accurate reporting of tumor type is crucial for coding.

Coding Guidelines

Inclusion Criteria

Use D11.9 When
  • According to ICD
  • 10 coding guidelines, D11
  • 9 should be used when a benign neoplasm of a major salivary gland is diagnosed but the specific type is not documented
  • Coders should ensure that the documentation supports the diagnosis and that there are no indications of malignancy

Exclusion Criteria

Do NOT use D11.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

42500CPT Code

Excision of benign tumor of salivary gland

Clinical Scenario

Used when a benign neoplasm is surgically removed.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Otolaryngologists should ensure clear documentation of the tumor's benign nature.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of benign neoplasms, improving the accuracy of data collection and reimbursement processes. D11.9 serves as a catch-all for unspecified benign neoplasms, but coders are encouraged to use more specific codes when possible to enhance clinical clarity.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of benign neoplasms, improving the accuracy of data collection and reimbursement processes. D11.9 serves as a catch-all for unspecified benign neoplasms, but coders are encouraged to use more specific codes when possible to enhance clinical clarity.

Reimbursement & Billing Impact

reimbursement processes. D11.9 serves as a catch-all for unspecified benign neoplasms, but coders are encouraged to use more specific codes when possible to enhance clinical clarity.

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 D11.9?

Coding D11.9 is significant as it indicates a benign neoplasm of the major salivary gland, which requires monitoring and may necessitate surgical intervention. Accurate coding ensures appropriate management and resource allocation.