2025 ICD-10-CM code C09

Malignant neoplasm of tonsil.

Code C09 is used for malignant neoplasms of the tonsil, excluding the lingual and pharyngeal tonsils.If the neoplasm overlaps contiguous sites, consider using subcategory .8 ('overlapping lesion') unless a specific combination code exists.For multiple non-contiguous tumors of the same site (e.g., different quadrants of the same tonsil), code each site separately.

Medical necessity for diagnostic and treatment procedures related to tonsil cancer should be established based on the patient's clinical presentation, confirmed diagnosis, and the stage of the cancer. The medical record should clearly document the rationale for chosen interventions, demonstrating their appropriateness for the individual case.

Clinicians should evaluate patients presenting with persistent sore throat, difficulty swallowing, ear pain, a lump in the throat, hoarseness, weight loss, or enlarged neck lymph nodes. Diagnostic procedures may include physical examination of the mouth, throat, and neck, biopsy of the lesion, fine needle aspiration, open biopsy of neck masses, endoscopy, imaging studies (X-ray, ultrasound, CT, MRI, PET scan). Treatment may involve chemotherapy, radiation therapy, surgery (tonsillectomy, removal of tumors/lymph nodes), or targeted chemotherapy.

IMPORTANT Excludes2: malignant neoplasm of lingual tonsil (C02.4) and malignant neoplasm of pharyngeal tonsil (C11.1).Use additional code to identify risk factors like alcohol abuse (F10.-), tobacco use/dependence (F17.-, Z72.0, Z87.891), and exposure to tobacco smoke (Z77.22, P96.81, Z57.31).

In simple words: Tonsil cancer is a type of cancer that starts in the tonsils, which are the two lumps of tissue at the back of your throat.Symptoms can include a sore throat that doesn't go away, pain in the ear, trouble swallowing, and a lump in your neck.

Malignant neoplasm of the tonsils. This refers to a cancerous growth originating in the tonsils, a pair of lymphoid masses located at the back of the throat.It's crucial to distinguish this from a peritonsillar abscess, which involves a pus collection near the tonsil but is not cancerous.Tonsil cancer is often linked to risk factors such as smoking, excessive alcohol consumption, and infection with the human papillomavirus (HPV).

Example 1: A patient presents with a persistent sore throat, difficulty swallowing, and an enlarged tonsil. Biopsy confirms malignant neoplasm of the tonsil., A patient with a history of heavy smoking and alcohol use exhibits a neck mass and enlarged lymph nodes. Further investigation reveals tonsil cancer with metastasis to the cervical lymph nodes., During a routine physical exam, asymmetry in the tonsils is noted. Subsequent biopsy reveals early-stage tonsil cancer in an otherwise asymptomatic patient.

Documentation should include details of the patient's symptoms, physical exam findings, biopsy results, imaging studies, and treatment plan. It should also note any relevant risk factors, such as tobacco and alcohol use or HPV infection.The stage of the cancer should be clearly documented, as it influences treatment decisions.

  • Specialties:Otolaryngology (ENT), Head and Neck Oncology, Radiation Oncology, Medical Oncology.
  • Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital,Office, Independent Clinic,Ambulatory Surgical Center.
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