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ICD-10 Guide
ICD-10 CodesD44.0

D44.0

Billable

Neoplasm of uncertain behavior of thyroid gland

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

Code Description

ICD-10 D44.0 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of thyroid gland.

Key Diagnostic Point:

Neoplasms of uncertain behavior of the thyroid gland refer to abnormal growths that do not fit the criteria for benign or malignant tumors. These neoplasms may present as nodules or masses within the thyroid and are often discovered incidentally during imaging studies or physical examinations. The behavior of these neoplasms is uncertain, meaning that while they may not exhibit aggressive characteristics, there is also a potential for malignant transformation. Surveillance is crucial for these patients, as regular monitoring through ultrasound and clinical evaluations can help detect any changes in size or characteristics that may indicate progression towards malignancy. The management of these neoplasms often involves a multidisciplinary approach, including endocrinologists, surgeons, and oncologists, to determine the best course of action, which may range from active surveillance to surgical intervention depending on the individual case. The uncertainty surrounding these neoplasms necessitates careful documentation and coding to ensure accurate representation of the patient's condition and treatment plan.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and behavior of neoplasms
  • Need for regular surveillance and monitoring
  • Potential for malignant transformation requiring careful assessment
  • Documentation of imaging and biopsy results

Audit Risk Factors

  • Inadequate documentation of surveillance findings
  • Failure to note changes in neoplasm characteristics
  • Misclassification as benign or malignant without proper evidence
  • Lack of multidisciplinary notes in the patient's record

Specialty Focus

Medical Specialties

Endocrinology

Documentation Requirements

Thorough documentation of clinical findings, imaging studies, and follow-up plans.

Common Clinical Scenarios

Patients presenting with thyroid nodules found incidentally on imaging.

Billing Considerations

Endocrinologists must document the rationale for surveillance versus intervention.

Surgery

Documentation Requirements

Detailed operative reports and pathology results if surgery is performed.

Common Clinical Scenarios

Patients requiring surgical evaluation for thyroid nodules with uncertain behavior.

Billing Considerations

Surgeons should document the decision-making process regarding the need for surgery.

Coding Guidelines

Inclusion Criteria

Use D44.0 When
  • According to ICD
  • 10 guidelines, D44
  • 0 should be used when the behavior of the neoplasm is uncertain, and it is essential to document the clinical rationale for this classification

Exclusion Criteria

Do NOT use D44.0 When
  • Exclusion criteria include definitive diagnoses of benign or malignant neoplasms

Related ICD-10 Codes

Related CPT Codes

85025CPT Code

Thyroid fine needle aspiration biopsy

Clinical Scenario

Used when a thyroid nodule is evaluated for potential malignancy.

Documentation Requirements

Document the indication for the biopsy and the results.

Specialty Considerations

Endocrinologists should ensure that the biopsy results are clearly linked to the diagnosis.

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

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.

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 growth that does not clearly classify as benign or malignant, requiring careful monitoring and evaluation.

How often should patients with D44.0 be monitored?

Patients should be monitored regularly, typically every 6 to 12 months, depending on the characteristics of the neoplasm.