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ICD-10 Guide
ICD-10 CodesD16.31

D16.31

Billable

Benign neoplasm of short bones of right lower limb

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

Code Description

ICD-10 D16.31 is a billable code used to indicate a diagnosis of benign neoplasm of short bones of right lower limb.

Key Diagnostic Point:

D16.31 refers to a benign neoplasm located in the short bones of the right lower limb, which includes the tarsal bones and metatarsals. Benign neoplasms are non-cancerous growths that do not invade surrounding tissues or metastasize to other parts of the body. Common types of benign neoplasms in this area include osteochondromas, enchondromas, and fibromas. These tumors may present with localized pain, swelling, or discomfort, particularly during physical activity. Diagnosis typically involves imaging studies such as X-rays, MRI, or CT scans to assess the size, location, and characteristics of the neoplasm. While benign, these neoplasms can sometimes cause complications, such as fractures or joint issues, necessitating monitoring and potential surgical intervention. Regular surveillance is recommended to ensure that the neoplasm remains stable and does not exhibit signs of malignant transformation, which, although rare, can occur in certain types of benign tumors. Treatment options may include observation, pain management, or surgical excision if symptomatic or if there is concern for malignancy.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Specificity of the anatomical location (right lower limb)
  • Differentiation from malignant neoplasms
  • Need for precise documentation of symptoms and imaging findings
  • Potential for co-existing conditions affecting coding

Audit Risk Factors

  • Inadequate documentation of the neoplasm's characteristics
  • Failure to specify the right lower limb location
  • Misclassification as malignant due to lack of clarity in pathology reports
  • Inconsistent reporting of symptoms or treatment plans

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed imaging reports, surgical notes if applicable, and follow-up assessments.

Common Clinical Scenarios

Patients presenting with localized pain in the foot or ankle, incidental findings on imaging, or post-surgical follow-ups.

Billing Considerations

Ensure clear documentation of the tumor's characteristics and any interventions performed.

Oncology

Documentation Requirements

Pathology reports confirming benign nature, imaging studies, and treatment plans.

Common Clinical Scenarios

Patients with a history of benign tumors requiring monitoring for potential malignant transformation.

Billing Considerations

Documentation must clearly differentiate between benign and malignant conditions to avoid coding errors.

Coding Guidelines

Inclusion Criteria

Use D16.31 When
  • According to ICD
  • 10 coding guidelines, D16
  • 31 should be used when the neoplasm is confirmed as benign through pathology
  • It is important to document the specific location and characteristics of the neoplasm

Exclusion Criteria

Do NOT use D16.31 When
  • Exclusion criteria include any malignant transformation or misclassification

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

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

Clinical Scenario

Used when a patient with a benign neoplasm presents with joint swelling.

Documentation Requirements

Document the reason for the procedure, findings, and any therapeutic interventions.

Specialty Considerations

Orthopedic specialists should ensure clear documentation of the relationship between the neoplasm and joint symptoms.

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. D16.31 provides a clear distinction for benign neoplasms of the right lower limb, which aids in clinical management and research.

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. D16.31 provides a clear distinction for benign neoplasms of the right lower limb, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. D16.31 provides a clear distinction for benign neoplasms of the right lower limb, which aids in clinical management and research.

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 D16.31 accurately?

Accurate coding of D16.31 is crucial for proper reimbursement, tracking of benign neoplasms, and ensuring appropriate clinical management. It helps in distinguishing benign conditions from malignant ones, which can significantly impact treatment decisions.