ICD-10 Logo
ICDxICD-10 Medical Coding
ICD-10 Logo
ICDxICD-10 Medical Coding
ICD 10 CodesDiagnoses
ICD 10 CodesDiagnoses
ICD-10 Logo
ICDxICD-10 Medical Coding

Comprehensive ICD-10-CM code reference with AI-powered search capabilities.

© 2025 ICD Code Compass. All rights reserved.

Browse

  • All Chapters
  • All Categories
  • Diagnoses

Tools

  • AI Code Search
ICD-10-CM codes are maintained by the CDC and CMS. This tool is for reference purposes only.
v1.0.0
ICD-10 Guide
ICD-10 CodesD41.9

D41.9

Billable

Neoplasm of uncertain behavior of unspecified urinary organ

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

Code Description

ICD-10 D41.9 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of unspecified urinary organ.

Key Diagnostic Point:

D41.9 refers to a neoplasm of uncertain behavior located in an unspecified urinary organ. Neoplasms of uncertain behavior are tumors that do not clearly fall into benign or malignant categories, making their management and prognosis challenging. These neoplasms may arise in various parts of the urinary system, including the kidneys, bladder, ureters, or urethra. The uncertainty surrounding their behavior necessitates careful monitoring and evaluation, as some may progress to malignancy while others may remain stable or regress. Surveillance strategies often include imaging studies and regular follow-ups to assess any changes in size or characteristics. The diagnosis is typically made through imaging and histological examination, where the pathologist may identify atypical cells but cannot definitively classify the tumor. This code is crucial for capturing the complexity of managing these tumors, which may require multidisciplinary approaches involving urologists, oncologists, and pathologists.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

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

Audit Risk Factors

  • Inadequate documentation of follow-up plans
  • Failure to specify the urinary organ involved
  • Lack of imaging results in the medical record
  • Misclassification of the neoplasm's behavior

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed imaging reports, pathology findings, and follow-up plans.

Common Clinical Scenarios

Patients with incidental findings on imaging, asymptomatic hematuria, or abnormal urinalysis results.

Billing Considerations

Urologists must ensure that all relevant imaging and pathology reports are included in the patient's medical record to support the diagnosis.

Oncology

Documentation Requirements

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

Common Clinical Scenarios

Patients with a history of urinary neoplasms requiring ongoing monitoring.

Billing Considerations

Oncologists should document the rationale for surveillance strategies and any changes in the neoplasm's behavior.

Coding Guidelines

Inclusion Criteria

Use D41.9 When
  • According to ICD
  • 10 coding guidelines, D41
  • 9 should be used when the neoplasm's behavior is uncertain and the specific urinary organ is not documented
  • Coders should ensure that the medical record supports the diagnosis and includes any relevant imaging or pathology reports

Exclusion Criteria

Do NOT use D41.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

88305CPT Code

Pathology examination, surgical

Clinical Scenario

Used when a biopsy is performed to assess the neoplasm's behavior.

Documentation Requirements

Pathology report detailing findings and behavior classification.

Specialty Considerations

Urologists and oncologists should ensure that the pathology report is comprehensive and includes all relevant 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. D41.9 captures the complexity of these cases, enabling better tracking and management of patients with uncertain neoplastic conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. D41.9 captures the complexity of these cases, enabling better tracking and management of patients with uncertain neoplastic conditions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. D41.9 captures the complexity of these cases, enabling better tracking and management of patients with uncertain neoplastic conditions.

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 medical knowledge and requires ongoing monitoring.

How often should patients with D41.9 be monitored?

Monitoring frequency depends on the specific clinical scenario but typically involves regular imaging and follow-up visits every 3 to 6 months.