ICD-10 Coding for Pineal Cyst(D35.4)
Complete ICD-10-CM coding and documentation guide for Pineal Cyst. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pineal Cyst
D35.2-D35.4Primary Range
Benign neoplasms of the endocrine glands
This range includes benign neoplasms of the pineal gland, which are coded under D35.4.
Key Information: ICD-10 code for pineal cyst
Essential facts and insights about Pineal Cyst
Primary ICD-10-CM Code for pineal cyst
Decision Criteria
clinical Criteria
- MRI shows a well-circumscribed cystic lesion ≤2 cm in pineal region without nodular enhancement
coding Criteria
- Avoid using E34.8 for structural lesions
Applicable To
- Benign pineal cyst
Excludes
- Malignant neoplasm of pineal gland
Clinical Validation Requirements
- MRI shows a well-circumscribed cystic lesion ≤2 cm in pineal region without nodular enhancement
- Histology confirms glial-lined cyst with pineal parenchyma
Code-Specific Risks
- Misclassification as an endocrine disorder using E34.8
Coding Notes
- Ensure documentation specifies 'benign neoplasm of pineal gland' to use D35.4.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral cysts
G93.0Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Other specified endocrine disorders
E34.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Pineal Cyst to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D35.4.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or audits.
Mitigation Strategy
Educate providers on documentation requirements, Use templates for consistent reporting
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate data on benign neoplasms.
Mitigation Strategy
Ensure documentation specifies 'benign neoplasm of pineal gland' and use D35.4.
Impact
Using E34.8 instead of D35.4 for benign pineal cysts.
Mitigation Strategy
Educate coders on the correct use of D35.4.
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 Pineal Cyst, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pineal Cyst
Use these documentation templates to ensure complete and accurate documentation for Pineal Cyst. These templates include all required elements for proper coding and billing.
Pineal cyst identified on MRI
Specialty: RadiologyRequired Elements
- Size and characteristics of the cyst
- Presence or absence of enhancement
- Comparison with previous imaging
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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