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ICD-10 Guide
ICD-10 CodesC65.2

C65.2

Billable

Malignant neoplasm of left renal pelvis

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

Code Description

ICD-10 C65.2 is a billable code used to indicate a diagnosis of malignant neoplasm of left renal pelvis.

Key Diagnostic Point:

C65.2 refers to a malignant neoplasm located in the left renal pelvis, which is the area of the kidney where urine collects before it moves to the ureter. This type of cancer is classified under urinary tract malignancies and is often associated with risk factors such as smoking, exposure to certain chemicals, and chronic irritation or inflammation of the urinary tract. Symptoms may include hematuria (blood in urine), flank pain, and urinary obstruction. Diagnosis typically involves imaging studies such as CT scans or MRIs, and confirmation is achieved through biopsy. Staging of renal pelvis cancer is crucial for determining the treatment approach and prognosis, with stages ranging from localized tumors to advanced disease that may have metastasized to lymph nodes or distant organs. Surgical management often involves nephroureterectomy, which is the removal of the affected kidney and ureter, and may be accompanied by lymph node dissection. Adjuvant therapies, including chemotherapy or immunotherapy, may also be considered based on the tumor's characteristics and stage.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between renal pelvis and other urinary tract cancers
  • Staging complexity due to various tumor characteristics
  • Need for precise documentation of tumor location and extent
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of tumor staging
  • Failure to specify laterality (left vs. right)
  • Misclassification of tumor type or location
  • Lack of supporting imaging or pathology reports

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed surgical notes, pathology reports, and imaging studies must be documented to support the diagnosis and treatment plan.

Common Clinical Scenarios

Urologists frequently encounter patients with hematuria, flank pain, or incidental findings on imaging that lead to further evaluation for renal pelvis tumors.

Billing Considerations

Urologists should ensure that all relevant clinical findings and treatment decisions are clearly documented to support coding and billing.

Oncology

Documentation Requirements

Oncologists must provide comprehensive treatment plans, including chemotherapy regimens and follow-up care details.

Common Clinical Scenarios

Oncologists often manage patients post-surgery for renal pelvis cancer, focusing on adjuvant therapies and monitoring for recurrence.

Billing Considerations

Accurate documentation of tumor characteristics and response to treatment is essential for coding and reimbursement.

Coding Guidelines

Inclusion Criteria

Use C65.2 When
  • According to ICD
  • 10 coding guidelines, C65
  • 2 should be used when the malignancy is confirmed and documented
  • It is important to include staging information and any relevant co
  • morbidities that may affect treatment

Exclusion Criteria

Do NOT use C65.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

50545CPT Code

Laparoscopic nephroureterectomy

Clinical Scenario

Used for surgical management of left renal pelvis malignancy.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Urologists should document the extent of the surgery and any complications.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urinary tract malignancies, improving the accuracy of data collection and reimbursement processes. C65.2 provides a clear distinction for left renal pelvis tumors, enhancing clinical understanding and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urinary tract malignancies, improving the accuracy of data collection and reimbursement processes. C65.2 provides a clear distinction for left renal pelvis tumors, enhancing clinical understanding and treatment planning.

Reimbursement & Billing Impact

reimbursement processes. C65.2 provides a clear distinction for left renal pelvis tumors, enhancing clinical understanding and treatment planning.

Resources

Clinical References

  • •
    American Urological Association Guidelines

Coding & Billing References

  • •
    American Urological Association Guidelines

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 weight loss and fatigue.