2025 ICD-10-CM code D48
Neoplasm of uncertain behavior of other and unspecified sites
Medical necessity is established by the presence of a neoplasm with uncertain behavior requiring further investigation to determine appropriate management.
Diagnosis involves physical examination, imaging studies, and biopsy for histopathological and cytological analysis. Treatment may involve surgical excision, radiation therapy, or chemotherapy depending on the location and potential for malignancy.
In simple words: This code refers to a growth or tumor in a location not otherwise specified, where doctors haven't yet determined if it's cancerous or not based on the examination of cells under a microscope.
This code represents a neoplasm of uncertain behavior affecting sites not specifically covered by other codes within the D48 category. It signifies a tumor whose benign or malignant nature cannot be definitively determined based on available histological evidence.
Example 1: A patient presents with a lump of uncertain nature in the soft tissue of the back. Biopsy results are inconclusive, leading to the use of D48 for coding until further investigation clarifies the diagnosis., An incidental finding on an imaging scan reveals a lesion in an unspecified deep tissue location. The nature of the lesion is undetermined after initial workup, necessitating the use of D48., A patient undergoes a biopsy for a suspicious skin lesion. The pathology report is inconclusive regarding its malignancy. D48 is used as a placeholder until additional tests are conducted.
Detailed clinical findings, imaging reports, and biopsy results with histopathological descriptions are necessary to support this code. Any additional diagnostic studies, consultations, or second opinions should also be documented.
** Excludes1: neurofibromatosis (nonmalignant) (Q85.0-)
- Specialties:Oncology, Pathology, General Surgery, potentially other specialties depending on the site of the neoplasm.
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office, Independent Clinic, other places of service depending on the clinical scenario.