2025 ICD-10-CM code D39.0
Neoplasm of uncertain behavior originating in the uterus.
Medical necessity for further investigation and treatment depends on the potential for malignancy.The uncertainty surrounding the diagnosis necessitates additional procedures and consultations to definitively characterize the lesion and rule out or confirm the presence of cancer.This helps guide appropriate treatment strategies and ensure optimal patient outcomes.
Clinicians diagnose this condition using patient history, symptoms (pelvic pain, unusual vaginal discharge or bleeding), physical examination, and imaging studies (ultrasound, CT, MRI, PET).Colposcopy, cystoscopy, and biopsies (cervical and/or endometrial) may be performed.Microscopic analysis of the biopsy is crucial but may not always yield a conclusive diagnosis.In such cases, a second opinion from another pathology lab may be sought. Treatment varies depending on the final diagnosis.
In simple words: An unusual growth has been found in the uterus (womb). It's not yet clear whether this growth is harmless or cancerous. More tests are needed to figure out what it is and what needs to be done.
A growth of abnormal tissue in the uterus, the nature of which (benign or malignant) cannot be definitively determined based on available histological examination.This indicates a need for further investigation to ascertain the definitive diagnosis and guide appropriate treatment.
Example 1: A 45-year-old woman experiences irregular vaginal bleeding and pelvic pain.A pelvic exam and ultrasound reveal a uterine mass. A biopsy is taken, and the pathology report returns as "neoplasm of uncertain behavior." Further testing, possibly including immunohistochemical staining or consultation with a specialist, is necessary to determine if the mass is benign or malignant., During a routine gynecological check-up, a small growth is discovered in a 60-year-old woman's uterus. An endometrial biopsy is performed, but the results are inconclusive, described as a neoplasm of uncertain behavior.Close monitoring and repeat biopsies might be recommended to assess any changes over time and guide further intervention., A 30-year-old woman undergoes surgery for a uterine fibroid.During the procedure, an additional, unexpected lesion is found.Pathological examination of the lesion yields a diagnosis of "neoplasm of uncertain behavior."Further studies, such as molecular testing, are required to establish a definitive diagnosis and determine the appropriate course of action.
Complete clinical documentation should include details of the patient's presentation, relevant medical history, findings from physical examination and imaging studies, biopsy procedure notes, and the initial pathology report indicating a neoplasm of uncertain behavior.Any subsequent testing or consultations should also be thoroughly documented.
** It's essential to distinguish this code (D39.0) which denotes uncertainty between benign and malignant potential, from codes for unspecified neoplasms (D49.-) which are used when the specific site or type is unknown. This distinction ensures accurate recording of the diagnostic uncertainty and guides appropriate clinical management.
- Payment Status: Active
- Specialties:Gynecology, Oncology, Pathology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office