What ICD-10 (International Classification of Diseases, 10th Revision) code is used for a mass on the kidney to get a Computed Tomography (CT) scan approved?

ICD-10 Coding for Kidney Mass to Obtain CT Approval

The most appropriate ICD-10 code for a mass on the kidney to get a CT scan approved is D41.0 (Neoplasm of uncertain behavior of kidney). 1

Understanding ICD-10 Coding for Renal Masses

When coding for a renal mass to obtain approval for CT imaging, the following options are available based on the clinical scenario:

Primary Coding Options:

• D41.0: Neoplasm of uncertain behavior of kidney
  • Most appropriate for initial evaluation of an indeterminate renal mass
  • Indicates the mass requires further investigation to determine if benign or malignant
  • Highest likelihood of CT approval as it directly supports the medical necessity

Alternative Coding Options Based on Clinical Context:

• R93.4: Abnormal findings on diagnostic imaging of urinary organs

  • Use when the mass was initially detected on another imaging modality (like ultrasound)
  • Less specific than D41.0 but still applicable

• N28.89: Other specified disorders of kidney and ureter

  • Can be used for non-neoplastic appearing masses

CT Protocol Considerations

The American College of Radiology recommends the following for evaluating indeterminate renal masses 1, 2:

• Multiphase CT protocol including:
  • Unenhanced phase
  • Contrast-enhanced phases (corticomedullary/arterial and nephrographic)
  • Thin-slice acquisition (≤5mm)

Important Clinical Considerations

When Coding for CT Approval:

• Document any symptoms that may be associated with the renal mass (hematuria, flank pain)
• Note any risk factors for renal cell carcinoma (smoking, obesity, family history) 3
• Include information about any previous imaging findings

Potential Pitfalls:

• Avoid using symptom-based codes alone (R10.9 for abdominal pain) as they may not justify the need for CT
• Do not use definitive diagnosis codes (C64 for malignant neoplasm of kidney) unless pathologically confirmed
• Be aware that small renal masses (≤1.5 cm) may show pseudoenhancement on CT due to beam hardening artifacts 2

Clinical Decision Algorithm

1. For newly discovered renal mass with no prior workup:

   • Use D41.0 (Neoplasm of uncertain behavior of kidney)

2. For follow-up of previously identified renal mass:

   • Use D41.0 with Z08.9 (Follow-up examination after treatment for malignant neoplasm)

3. For renal mass identified on other imaging:

   • Use R93.4 (Abnormal findings on diagnostic imaging of urinary organs)

4. For patients with contraindications to CT contrast:

   • Consider MRI with appropriate ICD-10 code D41.0
   • Document contrast contraindication in the order

Remember that according to the ACR Appropriateness Criteria, CT abdomen without and with IV contrast is usually appropriate for the initial imaging of an indeterminate renal mass in patients without contraindications to iodinated contrast 1.