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ICD-10 Guide
ICD-10 CodesChapter 2: NeoplasmsD39

D39

Billable

Neoplasm of uncertain behavior of female genital organs

Chapter 2:Neoplasms

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

Code Description

ICD-10 D39 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of female genital organs.

Key Diagnostic Point:

D39 refers to neoplasms of uncertain behavior affecting the female genital organs, which include the uterus, ovaries, fallopian tubes, vagina, and vulva. These neoplasms are characterized by atypical cellular features that do not clearly indicate malignancy or benignity. The uncertain behavior classification implies that the neoplasm may have the potential for progression to malignancy, necessitating careful monitoring and follow-up. Clinicians often perform imaging studies, biopsies, and other diagnostic procedures to assess the nature of these neoplasms. The management of patients with D39 may involve surgical intervention, observation, or further diagnostic evaluation, depending on the clinical scenario. Surveillance is crucial, as some neoplasms may exhibit malignant transformation over time. Accurate coding of D39 is essential for appropriate treatment planning and resource allocation in healthcare settings.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and behavior of neoplasms
  • Need for comprehensive documentation to support diagnosis
  • Potential for progression to malignancy requiring ongoing surveillance
  • Differentiation from benign and malignant neoplasms

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to document follow-up plans or surveillance
  • Misclassification of neoplasm behavior
  • Lack of clear diagnostic criteria in medical records

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed clinical notes including imaging results, biopsy findings, and treatment plans.

Common Clinical Scenarios

Management of patients with abnormal imaging results or biopsy findings indicating uncertain behavior.

Billing Considerations

Ensure that all findings are clearly documented to support the diagnosis of D39.

Oncology

Documentation Requirements

Comprehensive cancer staging and treatment plans, including multidisciplinary evaluations.

Common Clinical Scenarios

Evaluation of neoplasms with potential for malignancy and planning for surveillance or intervention.

Billing Considerations

Collaboration with pathology for accurate diagnosis and behavior assessment.

Coding Guidelines

Inclusion Criteria

Use D39 When
  • According to ICD
  • 10 guidelines, D39 should be used when the behavior of the neoplasm is uncertain and cannot be classified as benign or malignant
  • Coders must ensure that the diagnosis is supported by appropriate clinical documentation and that the neoplasm is located in the female genital organs

Exclusion Criteria

Do NOT use D39 When
No specific exclusions found.

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed for neoplasms of uncertain behavior when surgical intervention is indicated.

Documentation Requirements

Operative report detailing findings and rationale for surgery.

Specialty Considerations

Gynecological oncology may require additional documentation for cancer staging.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. This specificity aids in better tracking of patient outcomes and resource allocation, enhancing the overall quality of care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. This specificity aids in better tracking of patient outcomes and resource allocation, enhancing the overall quality of care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. This specificity aids in better tracking of patient outcomes and resource allocation, enhancing the overall quality of care.

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 does 'uncertain behavior' mean in the context of D39?

Uncertain behavior indicates that the neoplasm exhibits atypical features that do not clearly classify it as benign or malignant, necessitating further evaluation and monitoring.