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ICD-10 Guide
ICD-10 CodesD21.4

D21.4

Billable

Benign neoplasm of connective and other soft tissue of abdomen

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

Code Description

ICD-10 D21.4 is a billable code used to indicate a diagnosis of benign neoplasm of connective and other soft tissue of abdomen.

Key Diagnostic Point:

D21.4 refers to benign neoplasms that arise from connective tissues and other soft tissues located in the abdominal region. These neoplasms can include lipomas, fibromas, and other soft tissue tumors that are non-cancerous. While benign, these tumors can still cause significant symptoms depending on their size and location, such as abdominal pain, discomfort, or obstruction of surrounding organs. Diagnosis typically involves imaging studies such as ultrasound, CT scans, or MRI to assess the size and characteristics of the neoplasm. Surgical excision is often the preferred management approach, especially if the tumor is symptomatic or growing. Follow-up care is essential to monitor for recurrence, although benign tumors generally have a low risk of returning after complete removal. Accurate coding requires thorough documentation of the tumor's characteristics, location, and any associated symptoms or treatments.

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 overlapping symptoms with other abdominal conditions

Audit Risk Factors

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

Specialty Focus

Medical Specialties

Surgical Oncology

Documentation Requirements

Detailed operative reports, pathology reports, and imaging studies.

Common Clinical Scenarios

Surgical excision of a lipoma or fibroma in the abdominal region.

Billing Considerations

Ensure that the pathology report confirms the benign nature of the neoplasm.

Radiology

Documentation Requirements

Imaging reports that detail the size, location, and characteristics of the neoplasm.

Common Clinical Scenarios

Imaging studies performed to evaluate abdominal masses.

Billing Considerations

Clear documentation of imaging findings to support the diagnosis.

Coding Guidelines

Inclusion Criteria

Use D21.4 When
  • According to ICD
  • 10 coding guidelines, D21
  • 4 should be used when a benign neoplasm of connective and other soft tissue of the abdomen is confirmed
  • It is important to document the specific type of neoplasm and any relevant symptoms

Exclusion Criteria

Do NOT use D21.4 When
  • Exclusions include malignant neoplasms and conditions that do not involve connective or soft tissue

Related ICD-10 Codes

Related CPT Codes

19120CPT Code

Excision, benign lesion, skin, subcutaneous tissue

Clinical Scenario

Used when excising a benign neoplasm from the abdominal wall.

Documentation Requirements

Operative report detailing the excision and pathology results.

Specialty Considerations

Surgical oncology must ensure accurate coding based on pathology findings.

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. D21.4 provides a clear distinction from malignant neoplasms, which is crucial for treatment planning and patient 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. D21.4 provides a clear distinction from malignant neoplasms, which is crucial for treatment planning and patient management.

Reimbursement & Billing Impact

reimbursement processes. D21.4 provides a clear distinction from malignant neoplasms, which is crucial for treatment planning and patient 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 types of tumors are classified under D21.4?

D21.4 includes benign tumors such as lipomas, fibromas, and other soft tissue tumors located in the abdomen. Each type may have specific characteristics that should be documented.