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2025 ICD-10-CM code D16.4

Benign neoplasm of the bones of the skull and face. This includes benign neoplasms of the maxilla (superior), orbital bone, keratocyst of maxilla, and keratocystic odontogenic tumor of maxilla.

Refer to ICD-10-CM guidelines for coding neoplasms. Use additional codes to specify any functional activity associated with the neoplasm (Chapter 4).

Medical necessity for treatment is based on the presence of symptoms, the impact on function, and the risk of complications. The documentation should clearly support the need for intervention.

Physicians diagnose this condition based on patient history, neurological examination, and imaging studies (X-ray, MRI, CT, bone scan). Biopsy may be performed to confirm the diagnosis. Treatment, if needed, typically involves surgical removal and sometimes physical therapy.

In simple words: A non-cancerous growth in the bones of the skull and face. It's not life-threatening but can sometimes cause problems depending on its location and size.It might cause pain, headaches, vision changes, or trouble hearing, breathing, or swallowing.

Benign neoplasm of bones of skull and faceBenign neoplasm of maxilla (superior)Benign neoplasm of orbital boneKeratocyst of maxillaKeratocystic odontogenic tumor of maxillaExcludes2: benign neoplasm of lower jaw bone (D16.5)

Example 1: A patient presents with persistent headaches and blurred vision. Imaging reveals a benign neoplasm of the orbital bone., A patient experiences facial pain and swelling. A biopsy of a lesion on the maxilla confirms a keratocystic odontogenic tumor., A child with a history of fractures in the skull sustains another fracture from a minor injury. A subsequent X-ray reveals a benign bone tumor at the site of the recurrent fractures.

Documentation should include the patient's symptoms, the location and size of the neoplasm, diagnostic results (imaging, biopsy), and treatment plan.

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