ICD-10 Coding for Renal Mass(C64.1, C64.2, C64.9)
Complete ICD-10-CM coding and documentation guide for Renal Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Renal Mass
C64-C64.9Primary Range
Malignant neoplasm of kidney, except renal pelvis
This range includes codes for malignant neoplasms of the kidney, specifying laterality.
Other disorders of kidney and ureter
This range includes codes for non-malignant conditions such as renal cysts.
Neoplasms of unspecified behavior
This range is used for neoplasms of uncertain behavior, including complex cysts without biopsy confirmation.
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 and biopsy confirms renal cell carcinoma. |
|
| C64.2 | Malignant neoplasm of left kidney, except renal pelvis | Use when imaging confirms a malignant mass in the left kidney and biopsy confirms renal cell carcinoma. |
|
| C64.9 | Malignant neoplasm of unspecified kidney, except renal pelvis | Use when imaging confirms a malignant mass in the kidney but laterality is not specified. |
|
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 renal mass
Essential facts and insights about Renal Mass
Primary ICD-10-CM Codes for renal mass
Decision Criteria
clinical Criteria
- Biopsy confirms renal cell carcinoma
documentation Criteria
- Imaging report specifies laterality and enhancement
Applicable To
- Renal cell carcinoma of right kidney
Excludes
- Malignant neoplasm of renal pelvis (C65.1)
Clinical Validation Requirements
- CT/MRI showing ≥20 HU enhancement
- Biopsy-proven RCC with subtype
Code-Specific Risks
- Incorrect laterality coding
- Coding without biopsy confirmation
Coding Notes
- Ensure laterality is documented and confirmed by imaging.
C64.2 - Malignant neoplasm of left kidney, except renal pelvis
Use when imaging confirms a malignant mass in the left kidney and biopsy confirms renal cell carcinoma.
Applicable To
- Renal cell carcinoma of left kidney
Excludes
- Malignant neoplasm of renal pelvis (C65.2)
Clinical Validation Requirements
- CT/MRI showing ≥20 HU enhancement
- Biopsy-proven RCC with subtype
Coding Notes
Ensure laterality is documented and confirmed by imaging.
C64.9 - Malignant neoplasm of unspecified kidney, except renal pelvis
Use when imaging confirms a malignant mass in the kidney but laterality is not specified.
Applicable To
- Renal cell carcinoma of unspecified kidney
Excludes
- Malignant neoplasm of renal pelvis (C65.9)
Clinical Validation Requirements
- CT/MRI showing ≥20 HU enhancement
- Biopsy-proven RCC with subtype
Coding Notes
Ensure laterality is documented and confirmed by imaging.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other specified disorders of kidney and ureter
N28.89Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Neoplasm of unspecified behavior of kidney
D49.51Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Renal 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 incorrect treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always verify laterality in imaging reports., Use structured templates that prompt for laterality.
Impact
Reimbursement: Potential denial of claims due to lack of confirmation., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation of patient condition.
Mitigation Strategy
Use renal mass code until biopsy confirms malignancy.
Impact
Reimbursement: Claims may be denied or require resubmission., Compliance: Violation of coding standards., Data Quality: Misleading clinical data affecting treatment decisions.
Mitigation Strategy
Verify laterality through imaging reports before coding.
Impact
High risk of audit if laterality is not documented.
Mitigation Strategy
Implement mandatory fields in EHR for laterality.
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 Renal Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Renal Mass
Use these documentation templates to ensure complete and accurate documentation for Renal Mass. These templates include all required elements for proper coding and billing.
Renal Mass Evaluation
Specialty: UrologyRequired Elements
- Mass size and location
- Enhancement characteristics
- Biopsy results
- CKD stage
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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