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ICD-10 Guide
ICD-10 CodesD28.1

D28.1

Billable

Benign neoplasm of vagina

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

Code Description

ICD-10 D28.1 is a billable code used to indicate a diagnosis of benign neoplasm of vagina.

Key Diagnostic Point:

Benign neoplasms of the vagina are non-cancerous growths that can arise from various tissues within the vaginal wall. These neoplasms may include fibromas, lipomas, and other soft tissue tumors. Clinically, they can present as asymptomatic masses or may cause symptoms such as vaginal bleeding, discharge, or discomfort during intercourse. Diagnosis is typically made through pelvic examination, imaging studies such as ultrasound or MRI, and sometimes biopsy to rule out malignancy. Management often involves monitoring for changes in size or symptoms, and surgical excision may be indicated if the neoplasm causes significant symptoms or if there is uncertainty regarding its nature. Follow-up care is essential to ensure that the neoplasm does not recur and to monitor for any potential complications. Regular gynecological examinations are recommended for early detection of any changes in the neoplasm's characteristics.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from malignant neoplasms
  • Variability in presentation and symptoms
  • Need for imaging studies for accurate diagnosis
  • Potential for co-existing conditions

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the size and location of the neoplasm
  • Lack of follow-up documentation
  • Misclassification as malignant neoplasm

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed documentation of the neoplasm's characteristics, including size, location, and any symptoms experienced by the patient.

Common Clinical Scenarios

Patients presenting with vaginal masses, abnormal bleeding, or pelvic pain.

Billing Considerations

Ensure that all imaging and biopsy results are included in the medical record to support the diagnosis.

Pathology

Documentation Requirements

Pathology reports must clearly indicate the benign nature of the neoplasm and any relevant histological findings.

Common Clinical Scenarios

Biopsy specimens from vaginal masses sent for histological evaluation.

Billing Considerations

Accurate coding requires correlation between clinical findings and pathology results.

Coding Guidelines

Inclusion Criteria

Use D28.1 When
  • According to ICD
  • 10 coding guidelines, D28
  • 1 should be used when a benign neoplasm of the vagina is confirmed

Exclusion Criteria

Do NOT use D28.1 When
  • Exclusion criteria include any neoplasm that is determined to be malignant or uncertain in nature

Related ICD-10 Codes

Related CPT Codes

58120CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed when a benign neoplasm requires surgical intervention.

Documentation Requirements

Operative report detailing the indication for surgery and findings.

Specialty Considerations

Gynecologists must ensure that the diagnosis aligns with the surgical procedure performed.

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. D28.1 provides a clear distinction from malignant conditions, which is crucial for patient management.

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. D28.1 provides a clear distinction from malignant conditions, which is crucial for patient management.

Reimbursement & Billing Impact

reimbursement processes. D28.1 provides a clear distinction from malignant conditions, which is crucial for patient management.

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 a benign neoplasm of the vagina?

Common symptoms may include vaginal bleeding, discharge, or discomfort during intercourse. However, many cases are asymptomatic and discovered incidentally during routine examinations.