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ICD-10 Guide
ICD-10 CodesD16.02

D16.02

Billable

Benign neoplasm of scapula and long bones of left upper limb

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

Code Description

ICD-10 D16.02 is a billable code used to indicate a diagnosis of benign neoplasm of scapula and long bones of left upper limb.

Key Diagnostic Point:

D16.02 refers to benign neoplasms located specifically in the scapula and long bones of the left upper limb. These neoplasms are non-cancerous growths that can arise from various tissues, including bone, cartilage, and fibrous tissue. Common types of benign neoplasms in this area include osteochondromas, enchondromas, and fibromas. While benign, these neoplasms can cause symptoms such as pain, swelling, or limited range of motion, depending on their size and location. Surveillance is often necessary to monitor for any changes in size or symptoms, as some benign neoplasms can exhibit growth patterns that may warrant further investigation. Although the risk of malignant transformation is low, it is essential for healthcare providers to remain vigilant, particularly in cases where the neoplasm exhibits atypical features or changes over time. Regular imaging studies, such as X-rays or MRIs, may be recommended to assess the neoplasm's characteristics and ensure it remains benign.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Specificity of location (left upper limb)
  • Differentiation from malignant neoplasms
  • Need for detailed documentation of symptoms
  • Potential for growth monitoring and follow-up imaging

Audit Risk Factors

  • Inadequate documentation of the neoplasm's characteristics
  • Failure to document follow-up imaging results
  • Misclassification as malignant due to lack of clarity
  • Inconsistent coding of symptoms associated with the neoplasm

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments.

Common Clinical Scenarios

Patients presenting with pain or swelling in the left upper limb, requiring imaging to assess for benign neoplasms.

Billing Considerations

Ensure clear documentation of the neoplasm's size, location, and any changes observed over time.

Radiology

Documentation Requirements

Comprehensive imaging reports detailing the characteristics of the neoplasm.

Common Clinical Scenarios

Imaging studies performed to evaluate suspected benign neoplasms in the scapula or long bones.

Billing Considerations

Accurate description of imaging findings is crucial for proper coding and follow-up recommendations.

Coding Guidelines

Inclusion Criteria

Use D16.02 When
  • According to ICD
  • 10 coding guidelines, D16
  • 02 should be used when the neoplasm is confirmed as benign and located specifically in the scapula or long bones of the left upper limb

Exclusion Criteria

Do NOT use D16.02 When
  • Exclusion criteria include any malignant neoplasms or neoplasms located in other anatomical sites

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

Arthrocentesis, aspiration and/or injection into a major joint or bursa

Clinical Scenario

Used when a patient with a benign neoplasm presents with joint swelling.

Documentation Requirements

Document the reason for the procedure and findings.

Specialty Considerations

Orthopedic specialists should ensure accurate coding of the procedure in relation 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 benign neoplasms, improving the accuracy of data collection and reimbursement processes. D16.02 provides a clear distinction for neoplasms located in the left upper limb, enhancing clinical documentation and care management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of benign neoplasms, improving the accuracy of data collection and reimbursement processes. D16.02 provides a clear distinction for neoplasms located in the left upper limb, enhancing clinical documentation and care management.

Reimbursement & Billing Impact

reimbursement processes. D16.02 provides a clear distinction for neoplasms located in the left upper limb, enhancing clinical documentation and care 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 a benign neoplasm in the scapula?

Common symptoms include localized pain, swelling, and limited range of motion in the affected area. Some patients may be asymptomatic.