Patient presents with complaints suggestive of renal cell carcinoma (RCC), including [list presenting symptoms, e.g., hematuria, flank pain, palpable abdominal mass, weight loss, fatigue].  Differential diagnosis includes renal cyst, renal adenoma, urothelial carcinoma, and other retroperitoneal masses.  Physical examination revealed [document relevant findings, e.g., palpable renal mass, costovertebral angle tenderness].  Imaging studies, including [specify imaging modality, e.g., CT abdomen pelvis with and without contrast, MRI abdomen, renal ultrasound], demonstrate a [description of lesion characteristics, e.g., heterogeneously enhancing renal mass measuring X cm located in the upper pole of the right kidney, evidence of renal vein thrombosis].  Laboratory results show [include relevant labs, e.g., elevated creatinine, anemia, hypercalcemia].  Biopsy is planned to confirm the diagnosis and determine the histologic subtype of renal cell carcinoma (clear cell, papillary, chromophobe, collecting duct, medullary).  Based on clinical presentation, imaging findings, and laboratory data, the presumptive diagnosis is renal cell carcinoma.  Staging workup will be performed including chest imaging to assess for pulmonary metastasis and bone scan to evaluate for bone involvement. Treatment options, including partial nephrectomy, radical nephrectomy, targeted therapy, immunotherapy, and active surveillance, will be discussed with the patient following histopathologic confirmation and staging.  Patient education regarding renal cancer prognosis, treatment side effects, and follow-up care will be provided.  Referral to oncology and urology has been made.  ICD-10 code C64.9 (malignant neoplasm of kidney, unspecified) is used preoperatively, and the final code will be determined after pathology review and staging.  CPT codes for diagnostic imaging, biopsy, and consultations will be documented accordingly.