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ICD-10 Guide
ICD-10 CodesD21.2

D21.2

Billable

Benign neoplasm of connective and other soft tissue of lower limb, including hip

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

Code Description

ICD-10 D21.2 is a billable code used to indicate a diagnosis of benign neoplasm of connective and other soft tissue of lower limb, including hip.

Key Diagnostic Point:

D21.2 refers to benign neoplasms that arise from connective and other soft tissues in the lower limb, including the hip region. These neoplasms can include lipomas, fibromas, and other soft tissue tumors that are non-cancerous. Clinically, these tumors may present as palpable masses, which can be asymptomatic or cause discomfort depending on their size and location. Diagnosis typically involves imaging studies such as ultrasound or MRI to assess the characteristics of the mass, followed by a biopsy if malignancy is suspected. Management often includes surgical excision, especially if the neoplasm is symptomatic or growing. Follow-up care is essential to monitor for recurrence, particularly in cases where complete excision may not have been achieved. The prognosis for patients with benign soft tissue neoplasms is generally favorable, with low rates of recurrence when appropriately managed.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of benign neoplasms that can be coded under this category
  • Need for precise documentation of tumor characteristics
  • Differentiation from malignant neoplasms
  • Potential for multiple neoplasms in a single patient

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-surgery

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the neoplasm, imaging results, and surgical notes.

Common Clinical Scenarios

Surgical excision of a lipoma in the thigh or fibroma in the knee region.

Billing Considerations

Ensure clear documentation of the surgical approach and any complications.

Oncology

Documentation Requirements

Comprehensive pathology reports and imaging studies.

Common Clinical Scenarios

Monitoring of benign tumors that may require observation or intervention.

Billing Considerations

Differentiation from malignant tumors is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use D21.2 When
  • According to ICD
  • 10 coding guidelines, D21
  • 2 should be used when the neoplasm is confirmed as benign and located specifically in the lower limb or hip
  • Documentation must support the diagnosis, including imaging and pathology reports

Exclusion Criteria

Do NOT use D21.2 When
  • Exclusions include malignant neoplasms and unspecified soft tissue tumors

Related ICD-10 Codes

Related CPT Codes

11400CPT Code

Excision, benign lesion

Clinical Scenario

Used when excising a benign neoplasm from the lower limb.

Documentation Requirements

Operative report detailing the excision and pathology results.

Specialty Considerations

Orthopedic surgeons must document the size and location of the lesion.

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. D21.2 provides a clear distinction for benign soft tissue tumors, which aids in clinical management and research.

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. D21.2 provides a clear distinction for benign soft tissue tumors, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. D21.2 provides a clear distinction for benign soft tissue tumors, which aids in clinical management and research.

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.