Find comprehensive information on Renal Mass diagnosis including clinical documentation, medical coding, ICD-10 codes, SNOMED CT codes, and healthcare guidelines. Learn about Renal Mass symptoms, differential diagnosis, treatment options, and pathology. This resource provides valuable insights for physicians, clinicians, coders, and healthcare professionals involved in the diagnosis and management of Renal Mass. Explore relevant information on renal neoplasm, kidney cancer, and renal tumor.
Also known as
Malignant neoplasm of kidney
Cancers specifically affecting the kidney.
Benign neoplasm of kidney
Non-cancerous growths or tumors in the kidney.
Other specified disorders of kidney
Includes renal masses not classified elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the renal mass malignant?
Yes
Laterality specified?
No
Is it a benign neoplasm?
When to use each related code
| Description |
|---|
| Renal mass (unspecified) |
| Renal cyst (simple) |
| Renal cell carcinoma |
Coding renal mass without specifying laterality (right, left, or bilateral) leads to inaccurate coding and claims.
Discrepancy between clinical diagnosis and imaging findings can cause coding errors for renal masses impacting DRG assignment.
Coding a renal mass as malignant without pathological confirmation leads to overcoding and potential compliance issues.
Patient presents with concerns regarding a potential renal mass. Chief complaints may include flank pain, hematuria, palpable abdominal mass, or incidental finding on imaging performed for unrelated reasons. Symptoms, if present, may be vague or nonspecific. Patient history includes relevant medical comorbidities such as hypertension, diabetes, smoking history, family history of renal cell carcinoma, or von Hippel-Lindau syndrome. Physical examination findings are documented, including blood pressure, abdominal palpation, and assessment for costovertebral angle tenderness. Initial laboratory workup includes complete blood count, basic metabolic panel, urinalysis, and coagulation studies. Imaging studies such as ultrasound, CT scan with and without contrast, or MRI of the abdomen and pelvis are essential for characterizing the renal mass, assessing size, location, and characteristics suggesting malignancy. Differential diagnosis includes renal cell carcinoma, renal oncocytoma, angiomyolipoma, renal cyst, and other less common renal neoplasms. Biopsy may be considered for definitive diagnosis, particularly in cases with indeterminate imaging findings. Treatment plan depends on the size, characteristics, and presumed histology of the mass, ranging from active surveillance for small, benign-appearing lesions to partial or radical nephrectomy for suspected malignancy. Referral to urology or oncology for further evaluation and management is warranted. The patient has been counseled regarding the potential risks and benefits of different treatment options. Follow-up imaging and laboratory studies will be scheduled to monitor the renal mass and assess response to therapy, if initiated. ICD-10 codes such as D41.1 (benign neoplasm of kidney), C64.9 (malignant neoplasm of kidney, unspecified), and C79.0 (secondary malignant neoplasm of kidney) may be applicable depending on the diagnostic findings. CPT codes for imaging, biopsy, and surgical procedures will be documented based on the specific interventions performed. Medical necessity for all procedures is documented and aligns with established clinical guidelines.