2025 ICD-10-CM code D40.1
Neoplasm of uncertain behavior of testis. This diagnosis describes a testicular tumor that cannot be definitively classified as benign or malignant based on initial histologic examination.
Medical necessity is established by the presence of a testicular neoplasm with uncertain behavior, requiring further investigation to determine appropriate management. The uncertainty of the diagnosis justifies additional diagnostic procedures and specialist consultations to guide treatment decisions.
Clinicians diagnose this condition based on patient history, physical exam, laboratory studies (including tumor markers and immunohistochemistry), and imaging studies (ultrasound, CT, MRI, PET). Treatment depends on the final diagnosis after further pathological review, and may range from watchful waiting to surgical intervention (orchiectomy), radiation therapy, and/or chemotherapy.
- 2 (Neoplasms)
- D40-D48 (Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes)
In simple words: A neoplasm of uncertain behavior of the testis means there's a growth in the testicle, but doctors can't tell yet if it's cancerous or not based on the initial tests. More tests and possibly specialist opinions are needed.
Neoplasm of uncertain behavior of testis. This condition refers to a tumor in the testicle where microscopic analysis of a biopsy specimen does not clearly indicate whether it is benign or malignant.Further investigation and expert consultation are often required.
Example 1: A 30-year-old male presents with a painless lump in his right testicle. Biopsy results are inconclusive, leading to a diagnosis of D40.1.A second pathology review is requested., A patient undergoes a testicular biopsy for suspected cancer. The pathology report returns with a diagnosis of D40.1. The physician recommends a repeat biopsy or other diagnostic tests to determine the nature of the neoplasm., A 60-year-old male with a history of cryptorchidism presents with testicular swelling. A biopsy reveals a neoplasm, but its behavior is uncertain. The code D40.1 is assigned while awaiting further diagnostic workup.
Documentation should include details of the patient's presenting symptoms, physical examination findings, results of laboratory and imaging studies, biopsy procedure notes, and pathology reports. If a second opinion is sought, the report from the consulting pathologist should also be included.
** This code is assigned when further investigation is required to determine whether the neoplasm is benign or malignant.A definitive diagnosis should be coded as soon as it is available.
- Payment Status: Active
- Specialties:Urology, Oncology, Pathology
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Independent Clinic