2025 ICD-10-CM code D39.1
Neoplasm of uncertain behavior of the ovary. Use additional code to identify any functional activity.
Medical necessity is determined by the potential for malignancy. The uncertain nature of the neoplasm necessitates further investigation and potential treatment to prevent the development or spread of cancer if it proves to be malignant.
Clinicians diagnose this condition based on patient history, signs and symptoms, and physical examination, along with procedures such as colposcopy, cystoscopy, and biopsy. Imaging studies such as ultrasound, CT scans, MRI, and PET scans may also be used. Microscopic analysis of a biopsy may be inconclusive, requiring further pathological review. Treatment varies depending on the final diagnosis, ranging from watchful waiting and supportive care for benign neoplasms to surgery, radiation therapy, and/or chemotherapy for malignant ones.It is crucial for coders to await the final pathology report for a definitive diagnosis before assigning a code. Assigning an unspecified code is discouraged, and waiting for definitive results is the best approach.
In simple words: Abnormal tissue growth in the ovaries that cannot be definitively classified as cancerous or non-cancerous. The ovary is a female reproductive gland that produces eggs.
Neoplasm of uncertain behavior of the ovary is a diagnosis that describes tumors that cannot be definitively classified as benign or malignant based on histologic examination. The ovary is one of two small reproductive glands located on either side of the uterus where eggs are produced.
Example 1: A 50-year-old woman presents with postmenopausal bleeding. An ultrasound reveals an ovarian mass. A biopsy is performed, and the pathology report indicates a neoplasm of uncertain behavior., A 30-year-old woman experiences pelvic pain and bloating. Imaging reveals an ovarian mass, and a biopsy is performed. The initial pathology is inconclusive, indicating a neoplasm of uncertain behavior. The sample is sent for further pathological review., A 60-year-old woman with a history of ovarian cysts undergoes a routine pelvic exam. A new mass is discovered, and a biopsy is performed. The pathology report describes a neoplasm of uncertain behavior.
Complete medical history, physical exam findings, imaging reports (ultrasound, CT, MRI, PET if performed), and detailed pathology reports are essential for accurate coding. The documentation should clearly state the uncertainty of the neoplasm's behavior.
** Refer to iFrameAI for up-to-date information and detailed guidance on this and related codes.It is important to consult with a qualified medical coding professional for the most accurate coding and billing practices.
- Specialties:Oncology, Gynecology, Pathology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office, Independent Clinic