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v1.0.0
ICD-10 Guide
ICD-10 CodesD21.21

D21.21

Billable

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

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

Code Description

ICD-10 D21.21 is a billable code used to indicate a diagnosis of benign neoplasm of connective and other soft tissue of right lower limb, including hip.

Key Diagnostic Point:

D21.21 refers to benign neoplasms that arise from connective and other soft tissues located in the right lower limb, including the hip region. These neoplasms can include a variety of tumors such as lipomas, fibromas, and other soft tissue tumors that are non-cancerous. Clinically, patients may present with a palpable mass, localized pain, or discomfort in the affected area. Diagnosis is typically confirmed through imaging studies such as ultrasound or MRI, and histological examination may be necessary for definitive diagnosis. Management often involves surgical excision, especially if the neoplasm is symptomatic or growing. Follow-up care is essential to monitor for recurrence, although benign neoplasms generally have a low risk of malignant transformation. The prognosis is typically excellent, with most patients experiencing complete resolution of symptoms post-treatment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of benign neoplasm types that can be coded under this category
  • Need for precise documentation of the location and type of neoplasm
  • Differentiation from malignant neoplasms in clinical documentation
  • Potential for overlapping codes with similar conditions

Audit Risk Factors

  • Inadequate documentation of the tumor's 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 operative reports and pathology results are essential.

Common Clinical Scenarios

Surgical excision of a lipoma or fibroma in the right lower limb.

Billing Considerations

Ensure clear documentation of the size, location, and histological type of the neoplasm.

Oncology

Documentation Requirements

Comprehensive patient history and imaging studies to rule out malignancy.

Common Clinical Scenarios

Monitoring of benign soft tissue tumors for changes in size or symptoms.

Billing Considerations

Differentiation from malignant tumors is crucial; thorough documentation of diagnostic imaging is required.

Coding Guidelines

Inclusion Criteria

Use D21.21 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the neoplasm's location and type
  • Include any relevant imaging or pathology reports to support the diagnosis

Exclusion Criteria

Do NOT use D21.21 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 right lower limb.

Documentation Requirements

Operative report detailing the size and location of the lesion.

Specialty Considerations

Orthopedic surgeons should document the type of neoplasm 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 benign neoplasms, improving the accuracy of data collection and reimbursement processes.

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.

Reimbursement & Billing Impact

reimbursement processes.

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.