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v1.0.0
ICD-10 Guide
ICD-10 CodesD41.1

D41.1

Billable

Neoplasm of uncertain behavior of renal pelvis

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

Code Description

ICD-10 D41.1 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of renal pelvis.

Key Diagnostic Point:

D41.1 refers to a neoplasm of uncertain behavior located in the renal pelvis, which is the area of the kidney where urine collects before moving to the ureter. Neoplasms of uncertain behavior are tumors that cannot be definitively classified as benign or malignant based on histological examination. This uncertainty poses challenges in management and surveillance, as these tumors may exhibit varying degrees of aggressiveness. Regular monitoring through imaging studies and clinical evaluations is essential to assess any changes in size or characteristics that may indicate progression towards malignancy. The renal pelvis is less commonly affected by neoplasms compared to other parts of the urinary tract, making the diagnosis and management of such tumors particularly complex. Clinicians must consider patient history, imaging findings, and biopsy results when determining the appropriate course of action, which may include surgical intervention or continued observation. The potential for progression necessitates a multidisciplinary approach involving urologists, oncologists, and pathologists to ensure optimal patient outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Histological uncertainty in classification
  • Need for ongoing surveillance and monitoring
  • Variability in clinical presentation
  • Potential for progression to malignancy

Audit Risk Factors

  • Inadequate documentation of tumor behavior
  • Failure to document surveillance plans
  • Misclassification of neoplasm type
  • Lack of interdisciplinary notes

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed imaging reports, biopsy results, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with hematuria or flank pain, requiring imaging and potential biopsy.

Billing Considerations

Ensure clear documentation of tumor characteristics and behavior to support coding.

Oncology

Documentation Requirements

Comprehensive treatment plans, including chemotherapy or surgical interventions, must be documented.

Common Clinical Scenarios

Management of patients with uncertain behavior tumors requiring oncological assessment.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use D41.1 When
  • According to ICD
  • 10 guidelines, D41
  • 1 should be used when a neoplasm of uncertain behavior is confirmed in the renal pelvis
  • It is important to document the uncertainty in behavior and any follow
  • up plans

Exclusion Criteria

Do NOT use D41.1 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 the renal pelvis neoplasm.

Documentation Requirements

Pathology report must be included.

Specialty Considerations

Urologists and pathologists must collaborate for accurate coding.

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, which aids in better tracking and management of these conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior, which aids in better tracking and management of these conditions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior, which aids in better tracking and management of these conditions.

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 based on current histological evaluation, necessitating careful monitoring.