ICD-10 Coding for Benign Neoplasm of Brain(D33.0, D33.2, Z86.011)
Complete ICD-10-CM coding and documentation guide for Benign Neoplasm of Brain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Benign Neoplasm of Brain
D33.0-D33.2Primary Range
Benign neoplasm of brain and other parts of central nervous system
This range covers benign neoplasms located in various parts of the brain, including supratentorial and unspecified regions.
Personal history of benign neoplasm of brain
Used for patients with a history of benign brain neoplasms after treatment or resection.
Benign neoplasm of meninges
This range is used for coding benign meningiomas, which are excluded from the D33 series.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| D33.0 | Benign neoplasm of brain, supratentorial | Use when the benign neoplasm is located in the supratentorial region of the brain. |
|
| D33.2 | Benign neoplasm of brain, unspecified | Use when the specific location within the brain is not documented. |
|
| Z86.011 | Personal history of benign neoplasm of brain | Use when documenting a patient's history of a benign brain neoplasm after treatment. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for benign neoplasm of brain
Essential facts and insights about Benign Neoplasm of Brain
Primary ICD-10-CM Codes for benign neoplasm of brain
Decision Criteria
clinical Criteria
- MRI shows well-defined margins without infiltration.
Applicable To
- Benign neoplasm of cerebral cortex
- Benign neoplasm of frontal lobe
Excludes
- Meningioma (D32.0)
Clinical Validation Requirements
- MRI showing well-circumscribed lesion
- Histological confirmation of benign nature
Code-Specific Risks
- Confusion with malignant neoplasms if histology is not confirmed
Coding Notes
- Ensure MRI and histology reports are available to confirm benign status.
D33.2 - Benign neoplasm of brain, unspecified
Use when the specific location within the brain is not documented.
Applicable To
- Benign neoplasm of brain, NOS
Excludes
- Meningioma (D32.0)
Clinical Validation Requirements
- Imaging studies indicating a non-specific benign lesion
- Lack of specific location documentation
Coding Notes
Encourage documentation of specific brain regions to avoid using unspecified codes.
Z86.011 - Personal history of benign neoplasm of brain
Use when documenting a patient's history of a benign brain neoplasm after treatment.
Applicable To
- History of benign brain tumor
Excludes
- Current benign brain neoplasm (D33.x)
Clinical Validation Requirements
- Documented history of resection or treatment
- No active neoplasm present
Coding Notes
Ensure the neoplasm is not currently active before using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Headache
R51.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Benign Neoplasm of Brain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D33.0.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials due to insufficient documentation.
Mitigation Strategy
Ensure biopsy results are documented, Cross-check with pathology reports
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use D33.x for active benign neoplasms and Z86.011 only for history.
Impact
Using Z86.011 for active neoplasms can trigger audits.
Mitigation Strategy
Regular training on code differentiation and documentation review.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Benign Neoplasm of Brain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Benign Neoplasm of Brain
Use these documentation templates to ensure complete and accurate documentation for Benign Neoplasm of Brain. These templates include all required elements for proper coding and billing.
Neurosurgery Progress Note
Specialty: NeurosurgeryRequired Elements
- Location
- Size
- Characteristics
- Symptoms
- Histology
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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