2025 ICD-10-CM code C09.9
(Active) Effective Date: N/A Malignant neoplasms of lip, oral cavity and pharynx - Malignant neoplasm of tonsil, unspecified 2 Neoplasms (C00-D49) Feed
Malignant neoplasm of the tonsil, unspecified.
Medical necessity for treatment is established by the confirmed diagnosis of malignancy.The specific treatment approach is determined by the stage and characteristics of the cancer, patient health, and preferences.
Clinicians diagnose tonsillar malignancy through patient history, examination, biopsy, and imaging. They manage treatment, which may involve chemotherapy, radiation, surgery, and targeted therapy.
In simple words: This code refers to cancer of the tonsils.It's used when the doctor doesn't specify which part of the tonsil is affected.
Malignant neoplasm of the tonsils refers to a cancerous growth affecting the tonsils. This condition may present with symptoms such as a non-healing ulcer on the tonsil, persistent sore throat, ear pain, difficulty swallowing, a sensation of a lump in the throat, hoarseness, and unexplained weight loss.The ulcer may bleed and enlarge over time. Metastasis can lead to palpable lumps or masses in the neck and swollen lymph nodes. Diagnosis involves patient history, physical examination, biopsy, and imaging studies like X-rays, ultrasound, CT scans, MRI, and PET scans to determine the stage and extent of the malignancy. Treatment options include chemotherapy, radiation therapy, and surgery to remove the tonsils and affected lymph nodes. Targeted chemotherapy may also be employed.
Example 1: A patient presents with a persistent sore throat and an ulcer on their tonsil that won't heal.After a biopsy, the diagnosis is malignant neoplasm of the tonsil, unspecified., A patient with a history of heavy smoking and alcohol use has a painless lump in their neck.Imaging reveals a malignant neoplasm of the tonsil with lymph node involvement., A patient experiences difficulty swallowing and a feeling of fullness in their throat.A biopsy confirms a malignant neoplasm of the tonsil, and further imaging is needed for staging.
Documentation should include details of the patient's symptoms, physical exam findings, biopsy results, imaging reports, and treatment plan.The absence of specific site details within the tonsil should be noted.
** Consider additional codes for functional status, tobacco/alcohol use and HPV status when applicable.
- Specialties:Otolaryngology, Hematology-Oncology, Radiation Oncology
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center