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ICD-10 Guide
ICD-10 CodesD21.10

D21.10

Billable

Benign neoplasm of connective and other soft tissue of unspecified upper limb, including shoulder

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

Code Description

ICD-10 D21.10 is a billable code used to indicate a diagnosis of benign neoplasm of connective and other soft tissue of unspecified upper limb, including shoulder.

Key Diagnostic Point:

D21.10 refers to benign neoplasms that arise from connective tissues or other soft tissues in the upper limb, including the shoulder. These neoplasms can include lipomas, fibromas, and other non-cancerous growths that may develop in muscles, tendons, ligaments, or subcutaneous tissues. While benign, these tumors can cause discomfort, pain, or functional impairment depending on their size and location. Diagnosis typically involves imaging studies such as ultrasound or MRI, and may require biopsy for definitive identification. Management often includes observation, surgical excision, or other interventions based on symptoms and the neoplasm's characteristics. Follow-up care is essential to monitor for any changes in size or symptoms, ensuring that any potential complications are addressed promptly.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms of benign neoplasms
  • Need for precise documentation of tumor characteristics
  • Differentiation from malignant neoplasms
  • Potential for multiple neoplasms in a single patient

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to specify the location of the neoplasm
  • Misclassification as malignant neoplasm
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the neoplasm's size, location, and symptoms.

Common Clinical Scenarios

Surgical excision of a lipoma in the shoulder region.

Billing Considerations

Ensure clear documentation of the surgical approach and any complications.

Oncology

Documentation Requirements

Comprehensive reports on imaging studies and biopsy results.

Common Clinical Scenarios

Monitoring of benign tumors that may require intervention.

Billing Considerations

Differentiation from malignant tumors is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use D21.10 When
  • According to ICD
  • 10 guidelines, D21
  • 10 should be used when the neoplasm is confirmed as benign and the specific site is not documented
  • Coders must ensure that the diagnosis is supported by clinical documentation and imaging results

Exclusion Criteria

Do NOT use D21.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11400CPT Code

Excision, benign lesion including margins

Clinical Scenario

Used when excising a benign neoplasm from the upper limb.

Documentation Requirements

Document size, location, and pathology results.

Specialty Considerations

Orthopedic surgeons must detail the surgical approach and any complications.

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. D21.10 provides a clear designation for benign neoplasms in the upper limb, facilitating better patient management and tracking.

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. D21.10 provides a clear designation for benign neoplasms in the upper limb, facilitating better patient management and tracking.

Reimbursement & Billing Impact

reimbursement processes. D21.10 provides a clear designation for benign neoplasms in the upper limb, facilitating better patient management and tracking.

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 difference between benign and malignant neoplasms?

Benign neoplasms are non-cancerous growths that do not invade surrounding tissues or metastasize, while malignant neoplasms are cancerous and can spread to other parts of the body.