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ICD-10 Guide
ICD-10 CodesChapter 2: NeoplasmsD28

D28

Billable

Benign neoplasm of other and unspecified female genital organs

Chapter 2:Neoplasms

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

Code Description

ICD-10 D28 is a billable code used to indicate a diagnosis of benign neoplasm of other and unspecified female genital organs.

Key Diagnostic Point:

Benign neoplasms of the female genital organs can occur in various sites, including the vulva, vagina, cervix, uterus, and ovaries. These neoplasms are typically non-cancerous growths that may arise from epithelial or mesenchymal tissues. Common types include leiomyomas (fibroids) of the uterus, adenomas of the vulva, and various cysts. Symptoms may vary based on the location and size of the neoplasm, ranging from asymptomatic findings during routine examinations to pain, abnormal bleeding, or pressure symptoms. Diagnosis is often made through imaging studies such as ultrasound or MRI, and histological examination may be required for definitive diagnosis. Management typically involves monitoring for changes in size or symptoms, and surgical intervention may be indicated if the neoplasm causes significant symptoms or complications. Follow-up care is essential to ensure that the neoplasm remains benign and does not progress to malignancy.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of benign neoplasms that can be coded under this category
  • Need for precise documentation to differentiate from malignant neoplasms
  • Potential for overlapping symptoms with other conditions
  • Variability in treatment approaches based on neoplasm type and location

Audit Risk Factors

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

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed descriptions of the neoplasm, including size, location, and symptoms.

Common Clinical Scenarios

Management of uterine fibroids, vulvar lesions, and ovarian cysts.

Billing Considerations

Ensure accurate differentiation between benign and malignant conditions, and document any imaging or biopsy results.

Pathology

Documentation Requirements

Histopathological reports detailing the nature of the neoplasm.

Common Clinical Scenarios

Evaluation of biopsies from suspected benign neoplasms.

Billing Considerations

Clear documentation of the histological type is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use D28 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation
  • Include any relevant imaging or pathology reports to substantiate the diagnosis

Exclusion Criteria

Do NOT use D28 When
No specific exclusions found.

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed for symptomatic uterine fibroids.

Documentation Requirements

Indicate the reason for surgery and any pre-operative imaging findings.

Specialty Considerations

Gynecologists should document the size and location of fibroids.

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 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.