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D49.2
ICD-10-CM
Retroperitoneal Mass

Find comprehensive information on Retroperitoneal Mass diagnosis, including clinical documentation, medical coding, and healthcare guidelines. Learn about symptoms, diagnostic procedures, ICD-10 codes (C78.8, D48.7), differential diagnosis, and treatment options. This resource provides valuable insights for physicians, healthcare professionals, and medical coders seeking accurate and up-to-date information on retroperitoneal tumors, masses, and neoplasms. Explore relevant medical terminology and clinical findings associated with retroperitoneal masses for improved patient care and documentation.

Also known as

Retroperitoneal Tumor
Retroperitoneal Lesion

Diagnosis Snapshot

Key Facts
  • Definition : Abnormal tissue growth located behind the abdominal lining, potentially involving organs like kidneys, pancreas, or lymph nodes.
  • Clinical Signs : Often asymptomatic initially, but can cause abdominal pain, back pain, swelling, or weight loss.
  • Common Settings : Diagnosed via CT scans, MRI, biopsies in hospitals or specialized imaging centers.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC D49.2 Coding
C78.89

Secondary malignant neoplasm of other specified sites

Malignant tumor spread to the retroperitoneum from a primary site elsewhere.

D48.3

Neoplasm of uncertain behavior of retroperitoneum

Abnormal tissue growth in the retroperitoneum, uncertain if benign or malignant.

R91.8

Other abnormal findings on diagnostic imaging of abdomen

Unspecific abnormality found on abdominal imaging, possibly indicating a retroperitoneal mass.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the retroperitoneal mass a neoplasm?

  • Yes

    Malignant?

  • No

    Is it a hematoma?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Retroperitoneal mass
Lipoma
Liposarcoma

Documentation Best Practices

Documentation Checklist
  • Retroperitoneal mass location, size, characteristics documented.
  • Symptoms and related physical exam findings clearly noted.
  • Imaging study results (CT, MRI, US) with specific measurements.
  • Differential diagnosis considered and rationale for diagnosis.
  • Biopsy results (if performed) and pathology details included.

Coding and Audit Risks

Common Risks
  • Unspecified Location

    Coding retroperitoneal mass without laterality or specific organ involvement leads to inaccurate documentation and claims.

  • Missed Primary Malignancy

    Failing to code the primary malignancy when the retroperitoneal mass is metastatic impacts cancer registry data and reimbursement.

  • Inconsistent Imaging Documentation

    Discrepancies between imaging reports and clinical documentation for retroperitoneal mass size and characteristics create coding ambiguity.

Mitigation Tips

Best Practices
  • Document precise mass location, size, and characteristics for accurate ICD-10 coding (C78.7).
  • Ensure complete history and physical exam details for HCC risk adjustment and RAF scores.
  • Correlate imaging findings (CT/MRI/US) with clinical presentation for improved CDI and coding specificity.
  • Clearly document biopsy results and pathology for accurate diagnosis coding and treatment planning.
  • Regularly audit retroperitoneal mass documentation for compliance with coding guidelines and payer requirements.

Clinical Decision Support

Checklist
  • Verify laterality (left vs. right)
  • Confirm location (perinephric, etc.)
  • Document size and characteristics (cystic, solid, etc.)
  • Review imaging for lymphadenopathy
  • Assess for constitutional symptoms (fever, weight loss)

Reimbursement and Quality Metrics

Impact Summary
  • Retroperitoneal Mass reimbursement hinges on accurate ICD-10-CM coding (C78.6) and CPT coding for procedures like biopsies, imaging, and surgery. Impacts: higher CMI, appropriate DRG assignment.
  • Quality metrics impacted by accurate documentation, timely diagnosis, staging, and treatment plan. Impacts: improved patient outcomes, reduced complications, optimized resource use.
  • Precise coding of retroperitoneal mass size and location impacts staging and treatment, influencing reimbursement and quality reporting. Impacts: accurate cancer registry data, optimized LOS.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code location, laterality
  • Document mass size, characteristics
  • Specify imaging findings
  • Consider biopsy results for histology
  • Rule out primary neoplasms

Documentation Templates

Patient presents with [chief complaint related to retroperitoneal mass; e.g., abdominal pain, flank pain, abdominal distension, palpable mass, weight loss, or incidentally discovered on imaging].  Review of systems reveals [positive findings; e.g.,  nausea, vomiting, early satiety, change in bowel habits, hematuria, or no significant findings].  Past medical history includes [relevant medical conditions; e.g., hypertension, diabetes, prior abdominal surgeries, or family history of cancer].  Physical examination reveals [objective findings; e.g., palpable abdominal mass, tenderness to palpation, abdominal distension, or normal abdominal exam].  Imaging studies, including [CT scan, MRI, ultrasound, or PET scan], demonstrate a retroperitoneal mass measuring [size] cm located [location; e.g.,  adjacent to the kidney, pancreas, or aorta].  Differential diagnosis includes [lipoma, liposarcoma, leiomyosarcoma, lymphoma, neurogenic tumor, germ cell tumor, metastatic disease, or other retroperitoneal neoplasms].  Laboratory studies, including [complete blood count, comprehensive metabolic panel, tumor markers such as AFP, beta-hCG, LDH if indicated], are pending or show [results].  The patient was counseled on the potential need for biopsy or surgical resection for diagnostic and therapeutic purposes.  Risks and benefits of the procedures were discussed.  Patient understands the plan and will follow up for further evaluation and management of the retroperitoneal mass.  The plan includes [referral to surgery, oncology, or other specialties as indicated].  ICD-10 code [D48.3 - Neoplasm of uncertain behavior of retroperitoneum and peritoneum] and CPT codes for imaging and procedures performed will be used for medical billing and coding.  Further evaluation and management will be based on biopsy results and final diagnosis.