Find information on Right Renal Mass diagnosis, including clinical documentation, ICD-10 codes (C64.1, C64.9), medical coding guidelines, SNOMED CT concepts, differential diagnosis, and radiology reporting for accurate healthcare record keeping. Learn about renal tumor staging, workup, and treatment options. Explore resources for physicians, coders, and other healthcare professionals dealing with right kidney masses.
Also known as
Malignant neoplasms of kidney
Cancers specifically affecting the kidney.
Benign neoplasms of kidney
Non-cancerous growths or tumors in the kidney.
Other specified disorders of kidney
Includes unspecified renal masses or kidney lesions.
Abnormal findings on diagnostic imaging
Covers incidental findings like a mass discovered during imaging.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the right renal mass malignant?
Yes
Is it primary?
No
Is it benign?
When to use each related code
| Description |
|---|
| Right kidney mass |
| Right renal cyst |
| Right renal angiomyolipoma |
Coding a right renal mass without definitive imaging or biopsy confirmation can lead to inaccurate coding and potential denial of claims. Use of clinical indicators is vital for accurate coding.
Failing to code the correct laterality (right) for the renal mass may lead to incorrect reimbursement and data analysis issues. CDI should query for laterality if not documented.
Omitting documentation specifying whether the right renal mass is benign or malignant results in coding errors. Clear documentation and CDI queries help establish malignancy for optimal coding.
Q: What is the recommended initial imaging workup for an incidentally discovered right renal mass in an asymptomatic adult patient?
A: For an incidentally discovered, asymptomatic right renal mass, the recommended initial imaging workup typically involves a contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis. This allows for detailed characterization of the mass, including its size, location, density, enhancement characteristics, and relationship to surrounding structures. The CT scan helps distinguish between benign and malignant renal masses and guides further management decisions. Ultrasound can be considered an alternative initial imaging modality, especially in patients with contraindications to CT contrast, like chronic kidney disease, but it is usually less definitive. Consider implementing a standardized imaging protocol for renal masses to ensure consistent and high-quality data acquisition. Explore how contrast-enhanced CT can differentiate various renal lesions.
Q: How do I differentiate between a benign renal cyst and a renal cell carcinoma (RCC) on a CT scan when evaluating a right renal mass?
A: Differentiating a benign renal cyst from a renal cell carcinoma (RCC) on CT scan involves careful assessment of several key features. A simple renal cyst typically appears as a sharply demarcated, thin-walled, homogeneous, fluid-filled structure with no internal enhancement after contrast administration. Conversely, RCCs often exhibit features like irregular margins, heterogeneous internal density, nodular or irregular enhancement, and may demonstrate calcifications or areas of necrosis. Furthermore, RCC may demonstrate invasion into adjacent structures, such as the renal vein or perirenal fat. The Bosniak classification system can be a helpful tool in characterizing renal cysts and assessing their malignant potential. In cases where the imaging characteristics are indeterminate, biopsy or further imaging, such as MRI, might be necessary. Learn more about the Bosniak classification system and its application in differentiating renal masses.
Patient presents with complaints concerning for a right renal mass. Presenting symptoms include (but are not limited to) flank pain, hematuria, palpable abdominal mass, andor unintentional weight loss. Patient history includes (insert pertinent medical, surgical, family, and social history; specifically noting risk factors for renal cell carcinoma such as smoking, hypertension, obesity, family history of renal cancer, and exposure to certain chemicals). Physical examination reveals (insert relevant findings; such as palpable mass, costovertebral angle tenderness). Differential diagnosis includes renal cell carcinoma, renal cyst, renal oncocytoma, angiomyolipoma, and other less common renal neoplasms. Imaging studies (such as abdominal ultrasound, CT scan with and without contrast, MRI) were ordered to characterize the renal mass and assess its size, location, and characteristics. Laboratory tests including complete blood count, comprehensive metabolic panel, urinalysis, and coagulation studies were performed. Based on the clinical presentation, imaging findings, and laboratory results, the preliminary diagnosis of right renal mass is made. Further evaluation including biopsy or surgical resection may be necessary for definitive diagnosis and staging. Treatment options will be discussed with the patient, considering the specific characteristics of the mass, patient comorbidities, and patient preferences. The patient was counseled on the potential risks and benefits of each treatment option. Referral to urology or oncology may be warranted. Follow-up appointment scheduled for (date) to discuss results and plan further management. ICD-10 code (insert appropriate code such as C64.9 - Malignant neoplasm of kidney, unspecified) and CPT codes for procedures performed (e.g., 74170 for CT abdomen and pelvis) will be documented for medical billing and coding purposes. This documentation supports medical necessity for services rendered.