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Oncology & Hematology Coding Alert

READER QUESTION ~ Don't Assume Mass = Neoplasm

Published on Thu Jan 11, 2007

Question: When the oncologist documents a -renal mass,- is this the same as a neoplasm?

Oregon Subscriber

Answer: No. You shouldn't report 239.5 (Neoplasms of unspecified nature; other genitourinary organs) for a renal mass.
 
A mass such as a mass in the kidney may mean many things, including a malignant or benign process, abscess, cyst, or even a normal but hypertrophied portion of the kidney. You can't assume it is a neoplasm.

If you are unable to clarify the diagnosis with the physician, 593.9 (Unspecified disorder of kidney and ureter) is the most appropriate diagnosis. The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.
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