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ICD-10 Guide
ICD-10 CodesD16.2

D16.2

Billable

Benign neoplasm of long bones of lower limb

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

Code Description

ICD-10 D16.2 is a billable code used to indicate a diagnosis of benign neoplasm of long bones of lower limb.

Key Diagnostic Point:

Benign neoplasms of the long bones of the lower limb, such as the femur, tibia, and fibula, are non-cancerous growths that can arise from various tissues including bone, cartilage, and fibrous tissue. These neoplasms may present as asymptomatic or may cause localized pain, swelling, or functional impairment depending on their size and location. Common types include osteochondromas, enchondromas, and fibromas. Diagnosis typically involves imaging studies such as X-rays, CT scans, or MRIs, which help in visualizing the neoplasm's characteristics. While benign, these neoplasms require monitoring due to the potential for growth or complications such as fracture or compression of surrounding structures. Regular follow-up with imaging may be necessary to assess any changes in size or symptoms. Although the risk of malignant transformation is low, certain types of benign neoplasms, particularly those with atypical features, may warrant closer surveillance. Treatment options may include observation, surgical excision, or curettage, depending on the clinical scenario and patient factors.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of benign neoplasm types that can be coded under this category
  • Need for precise documentation of the neoplasm's characteristics and location
  • Potential for misclassification with malignant neoplasms
  • Variability in clinical presentation and treatment options

Audit Risk Factors

  • Inadequate documentation of the neoplasm's characteristics
  • Failure to document follow-up imaging or surveillance
  • Misclassification of benign neoplasms as malignant
  • Lack of clarity on the treatment plan or rationale for surgery

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments are essential.

Common Clinical Scenarios

Patients presenting with pain or swelling in the lower limb, incidental findings on imaging, or post-surgical follow-ups.

Billing Considerations

Ensure clear documentation of the neoplasm type, size, and any changes over time.

Radiology

Documentation Requirements

Comprehensive imaging reports detailing the characteristics of the neoplasm.

Common Clinical Scenarios

Imaging studies performed for evaluation of suspected benign neoplasms.

Billing Considerations

Accurate descriptions of imaging findings are crucial for proper coding.

Coding Guidelines

Inclusion Criteria

Use D16.2 When
  • According to ICD
  • 10 coding guidelines, D16
  • 2 should be used when a benign neoplasm of the long bones of the lower limb is confirmed through imaging or histological examination

Exclusion Criteria

Do NOT use D16.2 When
  • Exclusion criteria include any malignant transformation or neoplasms not specifically located in the long bones

Related ICD-10 Codes

Related CPT Codes

20680CPT Code

Arthrocentesis, aspiration and/or injection into a major joint or bursa

Clinical Scenario

Used when a patient with a benign neoplasm experiences joint effusion.

Documentation Requirements

Document the indication for the procedure and findings.

Specialty Considerations

Orthopedic specialists should ensure clear linkage between the diagnosis and the procedure.

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. This specificity aids in better tracking of treatment outcomes and resource utilization.

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. This specificity aids in better tracking of treatment outcomes and resource utilization.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better tracking of treatment outcomes and resource utilization.

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 monitoring benign neoplasms?

Monitoring benign neoplasms is crucial as they can grow or cause complications, and certain types may have a low risk of malignant transformation. Regular imaging and clinical assessments help ensure timely intervention if necessary.