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ICD-10 Guide
ICD-10 CodesD41.00

D41.00

Billable

Neoplasm of uncertain behavior of unspecified kidney

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

Code Description

ICD-10 D41.00 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of unspecified kidney.

Key Diagnostic Point:

Neoplasms of uncertain behavior of the kidney represent a category of tumors that do not fit neatly into benign or malignant classifications. These tumors may exhibit atypical cellular characteristics, making it difficult to predict their clinical behavior. The term 'uncertain behavior' indicates that while the neoplasm is not classified as malignant, there is a potential for progression to malignancy or aggressive behavior. Surveillance is crucial for these neoplasms, as they may require regular imaging and monitoring to assess any changes in size or characteristics. The kidney, being a vital organ, necessitates careful evaluation of any neoplastic growths, especially when the behavior is uncertain. Clinicians often rely on imaging studies, such as ultrasound or CT scans, and may recommend biopsy for definitive diagnosis. The management of these neoplasms can vary significantly based on individual patient factors, including age, overall health, and the specific characteristics of the tumor. Regular follow-up is essential to ensure timely intervention if the neoplasm shows signs of progression.

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 other renal neoplasms

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to document surveillance and follow-up plans
  • Misclassification of neoplasm behavior
  • Lack of clarity in pathology reports

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans must be documented.

Common Clinical Scenarios

Patients with renal masses undergoing surveillance or biopsy.

Billing Considerations

Ensure clear communication of tumor behavior and follow-up plans.

Urology

Documentation Requirements

Comprehensive notes on physical examinations, imaging results, and patient history.

Common Clinical Scenarios

Management of renal masses and decision-making regarding surgical intervention.

Billing Considerations

Document any changes in tumor size or characteristics during follow-up visits.

Coding Guidelines

Inclusion Criteria

Use D41.00 When
  • According to ICD
  • 10 guidelines, D41
  • 00 should be used when the neoplasm's behavior is uncertain and cannot be classified as benign or malignant
  • Coders should ensure that the diagnosis is supported by appropriate clinical documentation and that the neoplasm is located in the kidney

Exclusion Criteria

Do NOT use D41.00 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

88305CPT Code

Pathology examination, surgical

Clinical Scenario

Used when a biopsy is performed on a renal mass.

Documentation Requirements

Pathology report detailing findings and diagnosis.

Specialty Considerations

Oncologists and pathologists must collaborate for accurate diagnosis.

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 for surveillance and treatment.

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 for surveillance and treatment.

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 for surveillance and treatment.

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 'neoplasm of uncertain behavior' mean?

It refers to tumors that cannot be definitively classified as benign or malignant, indicating a potential for progression.

How often should patients with D41.00 be monitored?

Patients should undergo regular imaging and clinical evaluations, typically every 6 to 12 months, depending on the tumor characteristics.