ICD-10-CM Code for Left Submandibular Gland Mass (Possible Cystic Tumor)
For a left submandibular gland mass being evaluated as a possible cystic tumor of uncertain behavior, use ICD-10-CM code D37.032 (Neoplasm of uncertain behavior of the left major salivary gland).
Primary Code Selection
- D37.032 is the most appropriate code when imaging or clinical findings suggest a neoplasm but definitive histopathology has not yet confirmed benign versus malignant status 1
- This code specifically designates the left submandibular gland, which is one of the three major salivary glands 2
- The "uncertain behavior" classification (D37.x series) is used when a mass demonstrates features that cannot be definitively classified as benign or malignant without tissue diagnosis 1
Alternative Codes Based on Clinical Context
If the mass is confirmed as a simple cyst (non-neoplastic):
- K11.6 (Cyst of salivary gland) should be used instead when imaging clearly demonstrates a benign simple cyst without solid components, nodularity, or concerning features 1
- Simple cysts have smooth thin walls, are anechoic on ultrasound, and lack internal solid elements 1
If malignancy is confirmed on biopsy:
- C08.0 (Malignant neoplasm of submandibular gland) becomes the appropriate code once histopathology confirms malignancy 3, 4
- Approximately 50% of submandibular gland tumors are malignant, with adenoid cystic carcinoma and adenocarcinoma being most common 3, 4
If benign tumor is confirmed:
- D11.7 (Benign neoplasm of other major salivary glands) is used when pathology confirms a benign neoplasm such as pleomorphic adenoma 3
Clinical Documentation Requirements
- Document the laterality (left side) explicitly, as this affects code specificity 5
- Note whether the mass is cystic, solid, or mixed on imaging, as this influences differential diagnosis and coding 1
- Record any concerning features such as irregular borders, solid components, wall thickening, or nodularity that suggest malignant potential 1
- Include size measurements, as masses ≥1.5 cm warrant more aggressive evaluation 5
Common Coding Pitfalls to Avoid
- Do not use R22.1 (Localized swelling, mass and lump, neck) as the primary diagnosis when imaging has identified a specific glandular mass requiring further evaluation 5
- Avoid premature use of malignant codes (C08.0) before histopathologic confirmation, as this can affect insurance authorization and patient anxiety 3
- Do not code as K11.5 (Sialolithiasis) unless imaging demonstrates calculi as the primary pathology 6
- Ensure laterality is specified; unspecified codes (D37.039) should only be used when side cannot be determined 5