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v1.0.0
ICD-10 Guide
ICD-10 CodesD21.0

D21.0

Billable

Benign neoplasm of connective and other soft tissue of head, face and neck

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

Code Description

ICD-10 D21.0 is a billable code used to indicate a diagnosis of benign neoplasm of connective and other soft tissue of head, face and neck.

Key Diagnostic Point:

D21.0 refers to benign neoplasms that arise from connective and other soft tissues located in the head, face, and neck regions. These neoplasms can include a variety of tumors such as lipomas, fibromas, and neurofibromas, which are typically non-cancerous and may present as painless lumps or masses. The clinical presentation can vary significantly based on the specific type of neoplasm and its location. While these tumors are generally asymptomatic, they may cause discomfort or functional impairment depending on their size and location. Diagnosis is often made through physical examination, imaging studies, and sometimes biopsy. Management typically involves surgical excision, especially if the neoplasm is symptomatic or cosmetically concerning. Follow-up care is essential to monitor for recurrence, although benign neoplasms have a low rate of recurrence post-excision. Patient education regarding signs of changes in the neoplasm is also crucial for early detection of any potential complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of benign neoplasm types that can fall under this code
  • Need for precise documentation of tumor characteristics
  • Differentiation from malignant neoplasms
  • Variability in clinical presentation and management

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to specify the exact location of the neoplasm
  • Misclassification of benign neoplasms as malignant
  • Lack of follow-up documentation post-excision

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed descriptions of the neoplasm's location, size, and symptoms.

Common Clinical Scenarios

Management of benign tumors in the nasal cavity or throat.

Billing Considerations

Ensure clear documentation of any surgical interventions and follow-up care.

Dermatology

Documentation Requirements

Photographic evidence and detailed descriptions of skin lesions.

Common Clinical Scenarios

Excision of lipomas or dermatofibromas on the face.

Billing Considerations

Document cosmetic concerns and patient preferences regarding treatment.

Coding Guidelines

Inclusion Criteria

Use D21.0 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the neoplasm's characteristics and location
  • Include any relevant imaging or pathology reports to support the diagnosis

Exclusion Criteria

Do NOT use D21.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11400CPT Code

Excision, benign lesion

Clinical Scenario

Used when excising a benign neoplasm from the head or neck.

Documentation Requirements

Document the size, location, and type of neoplasm excised.

Specialty Considerations

Otolaryngologists and dermatologists should ensure detailed operative notes.

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. D21.0 provides a clear distinction for benign neoplasms in the head, face, and neck, which was less specific in ICD-9.

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. D21.0 provides a clear distinction for benign neoplasms in the head, face, and neck, which was less specific in ICD-9.

Reimbursement & Billing Impact

reimbursement processes. D21.0 provides a clear distinction for benign neoplasms in the head, face, and neck, which was less specific in ICD-9.

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 is the difference between benign and malignant neoplasms?

Benign neoplasms are non-cancerous growths that do not invade surrounding tissues or metastasize, while malignant neoplasms are cancerous and can spread to other parts of the body.