ICD-10 Coding for Right Renal Mass(C64.1, D49.51, N28.89)
Complete ICD-10-CM coding and documentation guide for Right Renal Mass. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Renal Mass
C64-C68Primary Range
Malignant neoplasms of urinary tract
This range includes codes for malignant neoplasms of the kidney, including C64.1 for malignant neoplasm of the right kidney.
Benign neoplasms of urinary organs
This range includes codes for benign neoplasms of the kidney, such as D30.01 for benign neoplasm of the right kidney.
Other disorders of kidney and ureter
This range includes codes for other specified disorders of the kidney, such as N28.89 for other specified disorders of kidney.
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 there is confirmed malignancy in the right kidney. |
|
| D49.51 | Neoplasm of uncertain behavior of right kidney | Use when the behavior of the renal mass is uncertain. |
|
| N28.89 | Other specified disorders of kidney and ureter | Use for benign renal conditions not classified elsewhere. |
|
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 right renal mass
Essential facts and insights about Right Renal Mass
Primary ICD-10-CM Codes for right renal mass
Decision Criteria
clinical Criteria
- Biopsy confirms renal cell carcinoma.
documentation Criteria
- Imaging shows enhancement >20 HU.
Applicable To
- Renal cell carcinoma of right kidney
Excludes
- Benign neoplasm of right kidney (D30.01)
Clinical Validation Requirements
- Biopsy-proven renal cell carcinoma
- Imaging showing enhancement >20 HU
Code-Specific Risks
- Coding without biopsy confirmation
- Omitting laterality
Coding Notes
- Ensure malignancy is confirmed before using this code.
D49.51 - Neoplasm of uncertain behavior of right kidney
Use when the behavior of the renal mass is uncertain.
Applicable To
- Indeterminate renal mass
Excludes
- Malignant neoplasm of right kidney (C64.1)
Clinical Validation Requirements
- Imaging shows indeterminate mass
- Biopsy pending or inconclusive
Coding Notes
Use when awaiting biopsy results or when imaging is inconclusive.
N28.89 - Other specified disorders of kidney and ureter
Use for benign renal conditions not classified elsewhere.
Applicable To
- Benign renal cyst
Excludes
- Malignant neoplasm of right kidney (C64.1)
Clinical Validation Requirements
- Imaging confirms benign cyst
Coding Notes
Ensure condition is benign and not better classified under another code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Right 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: Ambiguity in treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always specify right or left in documentation., Use structured templates.
Impact
Reimbursement: Incorrect DRG assignment leading to potential overpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Ensure biopsy or definitive imaging confirms malignancy before coding as C64.1.
Impact
Lack of biopsy confirmation for malignant coding.
Mitigation Strategy
Require biopsy results before coding malignancy.
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 Right Renal Mass, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Renal Mass
Use these documentation templates to ensure complete and accurate documentation for Right Renal Mass. These templates include all required elements for proper coding and billing.
Confirmed malignant right renal mass
Specialty: UrologyRequired Elements
- Biopsy results
- Imaging findings
- Clinical diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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