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ICD-10 Guide
ICD-10 CodesD41.01

D41.01

Billable

Neoplasm of uncertain behavior of right kidney

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

Code Description

ICD-10 D41.01 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of right kidney.

Key Diagnostic Point:

Neoplasms of uncertain behavior are tumors that do not fit neatly into benign or malignant categories. The diagnosis of a neoplasm of uncertain behavior of the right kidney indicates that the tumor has characteristics that suggest potential for malignancy but lacks definitive evidence to classify it as malignant. These neoplasms may exhibit atypical cellular features, and their behavior can vary significantly. Surveillance is crucial, as these tumors may progress to malignancy over time. Regular imaging studies, such as ultrasound or CT scans, are often employed to monitor changes in size or characteristics. The management of these neoplasms typically involves a multidisciplinary approach, including urologists and oncologists, to determine the best course of action, which may range from active surveillance to surgical intervention depending on the tumor's behavior and patient factors. Understanding the potential for progression is essential for patient management and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in tumor behavior and characteristics
  • Need for ongoing surveillance and monitoring
  • Potential for progression to malignancy
  • Multidisciplinary management approach

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to document surveillance imaging
  • Misclassification of tumor behavior
  • Lack of multidisciplinary notes in the medical record

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed imaging reports, biopsy results, and clinical notes on tumor behavior.

Common Clinical Scenarios

Initial diagnosis of a renal mass, follow-up imaging for tumor growth, and surgical intervention discussions.

Billing Considerations

Ensure clear documentation of tumor characteristics and any changes over time.

Oncology

Documentation Requirements

Comprehensive treatment plans, pathology reports, and follow-up care notes.

Common Clinical Scenarios

Management of patients with uncertain behavior tumors, including chemotherapy or radiation therapy discussions.

Billing Considerations

Document rationale for treatment decisions and any changes in tumor behavior.

Coding Guidelines

Inclusion Criteria

Use D41.01 When
  • According to ICD
  • 10 guidelines, D41
  • 01 should be used when the neoplasm is confirmed to be of uncertain behavior and specifically located in the right kidney
  • It is important to document the nature of the tumor and any relevant imaging or biopsy results

Exclusion Criteria

Do NOT use D41.01 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

88305CPT Code

Pathology examination of tissue

Clinical Scenario

Used when a biopsy is performed to assess the neoplasm.

Documentation Requirements

Pathology report must be included in the patient's medical record.

Specialty Considerations

Urologists and oncologists should ensure clear communication of findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. This specificity aids in better tracking and management of these conditions, improving patient care and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. This specificity aids in better tracking and management of these conditions, improving patient care and outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. This specificity aids in better tracking and management of these conditions, improving patient care and outcomes.

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 does 'neoplasm of uncertain behavior' mean?

It refers to tumors that exhibit atypical features that do not clearly classify them as benign or malignant, necessitating careful monitoring and evaluation.