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v1.0.0
ICD-10 Guide
ICD-10 CodesD41.4

D41.4

Billable

Neoplasm of uncertain behavior of bladder

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

Code Description

ICD-10 D41.4 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of bladder.

Key Diagnostic Point:

D41.4 refers to neoplasms of uncertain behavior specifically located in the bladder. These neoplasms are characterized by atypical cellular growth that does not clearly classify as benign or malignant. The behavior of these tumors can vary significantly, leading to challenges in diagnosis and management. Clinicians often rely on histopathological examination to determine the nature of the neoplasm. Surveillance is critical, as these neoplasms may have the potential for progression to malignancy. Regular monitoring through cystoscopy and imaging studies is recommended to assess changes in size, shape, or symptoms. The uncertainty surrounding these neoplasms necessitates a multidisciplinary approach involving urologists, oncologists, and pathologists to ensure appropriate management and follow-up. The prognosis can vary widely based on individual patient factors and the specific characteristics of the neoplasm, making it essential for healthcare providers to remain vigilant in their surveillance strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in histological findings
  • Need for ongoing surveillance and monitoring
  • Potential for progression to malignancy
  • Multidisciplinary management requirements

Audit Risk Factors

  • Inadequate documentation of surveillance protocols
  • Failure to capture the neoplasm's behavior accurately
  • Lack of follow-up notes or imaging results
  • Misclassification of neoplasm type

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed pathology reports, imaging studies, and follow-up notes are essential.

Common Clinical Scenarios

Patients presenting with hematuria or bladder mass requiring evaluation.

Billing Considerations

Ensure accurate staging and grading of neoplasms to guide treatment.

Oncology

Documentation Requirements

Comprehensive treatment plans and response assessments are necessary.

Common Clinical Scenarios

Management of patients with diagnosed bladder neoplasms undergoing chemotherapy or radiation.

Billing Considerations

Coordination with urology for surgical interventions and follow-up care.

Coding Guidelines

Inclusion Criteria

Use D41.4 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the neoplasm's behavior and any associated symptoms
  • Include relevant clinical findings and follow
  • up plans in the medical record

Exclusion Criteria

Do NOT use D41.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

52000CPT Code

Cystoscopy, diagnostic

Clinical Scenario

Used for initial evaluation of bladder neoplasms.

Documentation Requirements

Document indications for cystoscopy and findings.

Specialty Considerations

Urologists typically perform this procedure.

52224CPT Code

Cystourethroscopy with biopsy

Clinical Scenario

Performed when a neoplasm of uncertain behavior is suspected.

Documentation Requirements

Include biopsy results and follow-up plans.

Specialty Considerations

Ensure coordination between urology and pathology.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of neoplasms, improving the ability to track and manage conditions like D41.4. This specificity aids in research and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neoplasms, improving the ability to track and manage conditions like D41.4. This specificity aids in research and treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of neoplasms, improving the ability to track and manage conditions like D41.4. This specificity aids in research and treatment planning.

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 significance of coding D41.4?

Coding D41.4 is crucial for accurately representing neoplasms of uncertain behavior, which require careful monitoring and management due to their potential for progression to malignancy.