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v1.0.0
ICD-10 Guide
ICD-10 CodesChapter 2: NeoplasmsC65

C65

Billable

Malignant neoplasm of renal pelvis

Chapter 2:Neoplasms

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

Code Description

ICD-10 C65 is a billable code used to indicate a diagnosis of malignant neoplasm of renal pelvis.

Key Diagnostic Point:

Malignant neoplasm of the renal pelvis refers to cancer that originates in the renal pelvis, the area of the kidney where urine collects before moving to the ureter. This type of cancer is often associated with transitional cell carcinoma, which arises from the urothelium lining the renal pelvis. Risk factors include smoking, exposure to certain chemicals, and chronic urinary tract infections. Symptoms may include hematuria (blood in urine), flank pain, and urinary obstruction. Diagnosis typically involves imaging studies such as CT scans or MRIs, followed by biopsy for histological confirmation. Staging of renal pelvis cancer is crucial for determining treatment options and prognosis, often classified using the TNM system (Tumor, Node, Metastasis). Surgical management may include nephroureterectomy, where the affected kidney and ureter are removed, or less invasive procedures like endoscopic resection, depending on the tumor's size and location. Adjuvant therapies, including chemotherapy or immunotherapy, may also be considered based on the stage of the disease.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in staging and treatment options based on tumor size and location.
  • Need for precise documentation of imaging and biopsy results.
  • Differentiation from benign conditions and other urinary tract malignancies.
  • Potential for multiple surgical procedures and their coding.

Audit Risk Factors

  • Inadequate documentation of staging and treatment decisions.
  • Failure to capture all relevant imaging studies.
  • Misclassification of tumor type or grade.
  • Inconsistent coding of surgical procedures performed.

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed operative reports, imaging studies, and pathology results.

Common Clinical Scenarios

Diagnosis and management of renal pelvis tumors, surgical interventions, and follow-up care.

Billing Considerations

Ensure accurate staging and documentation of any adjuvant therapies.

Oncology

Documentation Requirements

Comprehensive treatment plans, chemotherapy regimens, and response assessments.

Common Clinical Scenarios

Management of advanced renal pelvis cancer, including systemic therapies.

Billing Considerations

Documenting the rationale for treatment choices and patient responses.

Coding Guidelines

Inclusion Criteria

Use C65 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, staging, and treatment
  • Include any relevant imaging or pathology reports to support the coding decision

Exclusion Criteria

Do NOT use C65 When
  • Exclude codes for benign conditions or other malignancies not affecting the renal pelvis

Related CPT Codes

50590CPT Code

Laparoscopic nephrectomy

Clinical Scenario

Used for surgical management of renal pelvis tumors.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Urology specialists should ensure accurate coding of the surgical approach.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of renal pelvis malignancies, improving the accuracy of data collection and treatment planning. C65 provides a clear distinction from other urinary tract cancers, facilitating better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of renal pelvis malignancies, improving the accuracy of data collection and treatment planning. C65 provides a clear distinction from other urinary tract cancers, facilitating better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of renal pelvis malignancies, improving the accuracy of data collection and treatment planning. C65 provides a clear distinction from other urinary tract cancers, facilitating better patient management.

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 are the common symptoms of malignant neoplasm of the renal pelvis?

Common symptoms include hematuria, flank pain, and urinary obstruction. Patients may also experience changes in urinary habits.

How is malignant neoplasm of the renal pelvis diagnosed?

Diagnosis typically involves imaging studies such as CT or MRI, followed by biopsy to confirm malignancy.

What staging system is used for renal pelvis cancer?

The TNM system is commonly used, which assesses tumor size, lymph node involvement, and metastasis.

What are the treatment options for this condition?

Treatment may include surgical resection, chemotherapy, and immunotherapy, depending on the stage of the cancer.