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ICD-10 Guide
ICD-10 CodesD21.9

D21.9

Billable

Benign neoplasm of connective and other soft tissue, unspecified

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

Code Description

ICD-10 D21.9 is a billable code used to indicate a diagnosis of benign neoplasm of connective and other soft tissue, unspecified.

Key Diagnostic Point:

D21.9 refers to a benign neoplasm of connective and other soft tissue that is unspecified. Benign neoplasms are non-cancerous growths that can occur in various tissues, including connective tissues such as cartilage, fat, and fibrous tissues. These neoplasms can arise in any part of the body, including the skin, muscles, and internal organs. While benign, they can still cause symptoms depending on their size and location, such as pain, discomfort, or functional impairment. Diagnosis typically involves imaging studies and histological examination to confirm the benign nature of the growth. Management may include observation, surgical excision, or other interventions based on the neoplasm's characteristics and the patient's symptoms. Follow-up care is essential to monitor for any changes in the neoplasm or the emergence of new symptoms. Accurate coding is crucial for proper reimbursement and to reflect the patient's clinical status in medical records.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms of benign neoplasms
  • Need for precise documentation to differentiate from malignant neoplasms
  • Potential for multiple sites of occurrence requiring site-specific coding
  • Variations in treatment approaches based on neoplasm location and size

Audit Risk Factors

  • Insufficient documentation of the neoplasm's characteristics
  • Failure to specify the location of the neoplasm
  • Inadequate follow-up documentation post-treatment
  • Misclassification of benign neoplasms as malignant

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports and imaging studies to confirm benign nature.

Common Clinical Scenarios

Patients presenting with soft tissue masses requiring biopsy or excision.

Billing Considerations

Ensure clear differentiation from malignant neoplasms in documentation.

Orthopedics

Documentation Requirements

Imaging results and surgical notes detailing the excision of soft tissue tumors.

Common Clinical Scenarios

Patients with soft tissue masses in limbs or joints.

Billing Considerations

Document functional impact and any associated symptoms.

Coding Guidelines

Inclusion Criteria

Use D21.9 When
  • According to ICD
  • 10 coding guidelines, D21
  • 9 should be used when the specific site of the benign neoplasm is not documented
  • Coders must ensure that the diagnosis is confirmed as benign through appropriate clinical documentation

Exclusion Criteria

Do NOT use D21.9 When
  • Exclusion criteria include any neoplasm that is confirmed malignant or has uncertain behavior

Related ICD-10 Codes

Related CPT Codes

19120CPT Code

Excision, benign tumor, skin, subcutaneous tissue

Clinical Scenario

Used when excising a benign neoplasm from the skin.

Documentation Requirements

Operative report detailing the excision and pathology results.

Specialty Considerations

Ensure the excision is documented as benign.

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 granularity of data collection and reimbursement processes. D21.9 serves as a catch-all for unspecified cases, but coders are encouraged to use more specific codes when available.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of benign neoplasms, improving the granularity of data collection and reimbursement processes. D21.9 serves as a catch-all for unspecified cases, but coders are encouraged to use more specific codes when available.

Reimbursement & Billing Impact

reimbursement processes. D21.9 serves as a catch-all for unspecified cases, but coders are encouraged to use more specific codes when available.

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

When should I use D21.9 instead of a more specific code?

D21.9 should be used when the specific site of the benign neoplasm is not documented or when the neoplasm's characteristics are not clearly defined in the medical record.