ICD-10 Coding for Kidney Mass(C64.1, N28.89)
Complete ICD-10-CM coding and documentation guide for Kidney Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Kidney Mass
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| C64.1 | Malignant neoplasm of right kidney, except renal pelvis | Use when imaging confirms a malignant mass in the right kidney. |
|
| N28.89 | Other specified disorders of kidney and ureter | Use for benign or unspecified renal masses. |
|
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 kidney mass
Essential facts and insights about Kidney Mass
Primary ICD-10-CM Codes for mass kidney
Decision Criteria
clinical Criteria
- Presence of solid renal mass with enhancement on imaging
documentation Criteria
- Biopsy results confirming malignancy
Applicable To
- Renal cell carcinoma of right kidney
Excludes
- Malignant neoplasm of renal pelvis (C65.1)
Clinical Validation Requirements
- CT/MRI showing solid component with enhancement >15 HU
- Biopsy confirmation of malignancy
Code-Specific Risks
- Incorrect laterality coding if imaging is not reviewed.
Coding Notes
- Ensure laterality is documented in imaging reports.
N28.89 - Other specified disorders of kidney and ureter
Use for benign or unspecified renal masses.
Applicable To
- Benign renal mass
Excludes
- Malignant neoplasm of kidney (C64-C65)
Clinical Validation Requirements
- Ultrasound/CT showing simple cyst or non-enhancing lesion
Coding Notes
Ensure imaging confirms benign nature of the mass.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Follow-up examination after treatment for malignant neoplasm
Z08Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Kidney Mass to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code C64.1.
Impact
Clinical: May lead to misclassification of mass type., Regulatory: Non-compliance with documentation standards., Financial: Potential reimbursement issues due to incorrect coding.
Mitigation Strategy
Ensure radiology reports include enhancement characteristics., Train staff on importance of detailed imaging documentation.
Impact
Reimbursement: May affect DRG assignment and reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Review imaging reports to confirm laterality before coding.
Impact
Reimbursement: Incorrect size may affect staging and reimbursement., Compliance: Non-compliance with documentation standards., Data Quality: Inaccurate clinical records.
Mitigation Strategy
Use operative notes for accurate tumor size documentation.
Impact
Failure to code laterality correctly can lead to audit flags.
Mitigation Strategy
Implement double-check system for laterality in imaging reports.
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 Kidney Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Kidney Mass
Use these documentation templates to ensure complete and accurate documentation for Kidney Mass. These templates include all required elements for proper coding and billing.
Radiology report for renal mass
Specialty: RadiologyRequired Elements
- Mass size
- Enhancement characteristics
- Bosniak classification
- Fat content
- Proximity to sinus/collecting system
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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