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ICD-10 Guide
ICD-10 CodesD16.4

D16.4

Billable

Benign neoplasm of bones of skull and face

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

Code Description

ICD-10 D16.4 is a billable code used to indicate a diagnosis of benign neoplasm of bones of skull and face.

Key Diagnostic Point:

Benign neoplasms of the bones of the skull and face are non-cancerous growths that arise from the bone tissue in these regions. These neoplasms can vary in size and may be asymptomatic or cause symptoms depending on their location and size. Common types include osteomas, which are slow-growing tumors that can occur in the skull, and other benign lesions such as fibrous dysplasia. While benign, these neoplasms can sometimes lead to complications such as pain, deformity, or neurological symptoms if they impinge on surrounding structures. Diagnosis typically involves imaging studies such as X-rays, CT scans, or MRIs, and may require biopsy for definitive diagnosis. Treatment options may include observation, surgical excision, or other interventions depending on the symptoms and potential complications. Regular surveillance may be necessary to monitor for any changes in size or symptoms, as well as to rule out the rare possibility of malignant transformation, although this is uncommon.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of benign neoplasm types that may require specific documentation.
  • Potential for overlapping symptoms with malignant conditions.
  • Need for precise imaging and diagnostic documentation.
  • Variability in treatment approaches based on symptoms and location.

Audit Risk Factors

  • Inadequate documentation of the benign nature of the neoplasm.
  • Failure to document the size and location of the neoplasm.
  • Lack of follow-up documentation for surveillance.
  • Misclassification of benign neoplasms as malignant.

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports and imaging studies.

Common Clinical Scenarios

Diagnosis and management of benign bone tumors.

Billing Considerations

Differentiating benign from malignant lesions is crucial.

Radiology

Documentation Requirements

Comprehensive imaging reports with clear descriptions.

Common Clinical Scenarios

Imaging for suspected benign neoplasms.

Billing Considerations

Accurate imaging interpretation is essential for diagnosis.

Coding Guidelines

Inclusion Criteria

Use D16.4 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, including size, location, and any symptoms

Exclusion Criteria

Do NOT use D16.4 When
  • Exclude malignant neoplasms and ensure that the benign nature is clearly documented

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 benign neoplasm causes joint symptoms.

Documentation Requirements

Document the reason for aspiration and findings.

Specialty Considerations

Orthopedic documentation may be required.

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.

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.

Reimbursement & Billing Impact

reimbursement processes.

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 are the common symptoms of benign neoplasms of the skull and face?

Common symptoms include painless lumps, facial asymmetry, and in some cases, neurological symptoms if the neoplasm compresses surrounding structures.