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ICD-10 Guide
ICD-10 CodesQ61.01

Q61.01

Billable

Congenital single renal cyst

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q61.01 is a billable code used to indicate a diagnosis of congenital single renal cyst.

Key Diagnostic Point:

Congenital single renal cyst refers to a fluid-filled sac that forms in the kidney during fetal development. This condition is classified under congenital malformations of the urinary system and is characterized by the presence of a single cyst that can vary in size. While many individuals with a single renal cyst may remain asymptomatic and lead normal lives, complications can arise, including hypertension or renal impairment if the cyst grows large enough to affect kidney function. The etiology of renal cysts can be multifactorial, including genetic predispositions and environmental factors. In pediatric patients, it is essential to monitor renal function and assess for any associated anomalies, such as renal agenesis or polycystic kidney disease, which may complicate the clinical picture. Diagnosis is typically made through imaging studies such as ultrasound, which can help differentiate between simple cysts and more complex renal masses. Management may involve regular monitoring, and in some cases, surgical intervention may be necessary if complications arise.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between simple and complex renal cysts
  • Potential association with other congenital anomalies
  • Need for imaging documentation
  • Variability in clinical presentation

Audit Risk Factors

  • Inadequate documentation of imaging studies
  • Failure to note associated congenital anomalies
  • Misclassification of cyst complexity
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Documentation should include detailed imaging reports, growth patterns of the cyst, and any associated symptoms or anomalies.

Common Clinical Scenarios

Pediatric patients presenting with abdominal pain or incidental findings on imaging during routine examinations.

Billing Considerations

Consideration of the child's growth and development, as well as potential psychosocial impacts of congenital conditions.

Genetics

Documentation Requirements

Genetic counseling notes, family history of renal anomalies, and any genetic testing results should be documented.

Common Clinical Scenarios

Patients with a family history of renal disease or syndromic presentations requiring genetic evaluation.

Billing Considerations

Understanding the genetic basis of renal cyst formation and implications for family members.

Coding Guidelines

Inclusion Criteria

Use Q61.01 When
  • Follow the official ICD
  • CM guidelines for coding congenital conditions, ensuring accurate documentation of the condition's nature and any associated anomalies

Exclusion Criteria

Do NOT use Q61.01 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

76700CPT Code

Ultrasound, abdomen, complete

Clinical Scenario

Used to evaluate renal cysts in pediatric patients.

Documentation Requirements

Document the reason for the ultrasound and findings.

Specialty Considerations

Pediatric specialists should ensure imaging is age-appropriate.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital conditions, 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 congenital conditions, 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 significance of a single renal cyst in a pediatric patient?

A single renal cyst is often benign and may not require intervention. However, it is essential to monitor for potential complications and associated anomalies, particularly in pediatric patients, as they may have implications for renal function and overall health.