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v1.0.0
ICD-10 Guide
ICD-10 CodesD41.2

D41.2

Billable

Neoplasm of uncertain behavior of ureter

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

Code Description

ICD-10 D41.2 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of ureter.

Key Diagnostic Point:

D41.2 refers to a neoplasm of uncertain behavior located in the ureter, which is the duct that carries urine from the kidneys to the bladder. Neoplasms of uncertain behavior are tumors that cannot be definitively classified as benign or malignant based on histological examination. This uncertainty necessitates careful monitoring and follow-up, as these tumors may exhibit varying degrees of aggressiveness. The ureter, being a tubular structure, can be affected by various types of neoplasms, including transitional cell carcinoma, which is the most common type of ureteral cancer. Patients with this diagnosis may present with hematuria, flank pain, or urinary obstruction. Surveillance strategies often include imaging studies and cystoscopy to monitor for changes in the neoplasm's behavior. The potential for progression to malignancy underscores the importance of regular follow-up and assessment, as timely intervention can significantly impact patient outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Uncertainty in behavior classification
  • Need for ongoing surveillance and follow-up
  • Variability in clinical presentation
  • Potential for progression to malignancy

Audit Risk Factors

  • Inadequate documentation of tumor behavior
  • Failure to document follow-up plans
  • Misclassification of neoplasm type
  • Lack of imaging reports in the medical record

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed pathology reports, imaging studies, and clinical notes regarding tumor behavior and follow-up plans.

Common Clinical Scenarios

Patients presenting with hematuria or flank pain, requiring imaging and potential intervention.

Billing Considerations

Urologists must ensure clear documentation of the neoplasm's behavior and any changes over time.

Oncology

Documentation Requirements

Comprehensive treatment plans, including surveillance strategies and any interventions performed.

Common Clinical Scenarios

Patients undergoing treatment for ureteral neoplasms, including chemotherapy or surgical interventions.

Billing Considerations

Oncologists should document the rationale for treatment decisions based on tumor behavior.

Coding Guidelines

Inclusion Criteria

Use D41.2 When
  • According to ICD
  • 10 guidelines, D41
  • 2 should be used when the neoplasm's behavior is uncertain and cannot be classified as benign or malignant
  • Documentation must support the diagnosis and indicate the need for surveillance

Exclusion Criteria

Do NOT use D41.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

52000CPT Code

Cystoscopy

Clinical Scenario

Used for direct visualization of the ureter and potential biopsy.

Documentation Requirements

Document indications for the procedure and findings.

Specialty Considerations

Urologists must ensure that the procedure is justified based on the patient's history and imaging results.

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, which aids in better tracking and management of these conditions.

ICD-9 vs ICD-10

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

Reimbursement & Billing Impact

reimbursement.

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 a tumor that cannot be definitively classified as benign or malignant based on current diagnostic criteria, necessitating careful monitoring.