2025 ICD-10-CM code D41.4
Neoplasm of uncertain behavior of the bladder.
Medical necessity for services related to D41.4 hinges on the uncertainty surrounding the diagnosis.The need for further investigation (e.g., repeat biopsies, imaging, specialist consultations) to determine the nature of the neoplasm and guide treatment must be clearly documented.
Diagnosis involves physical examination, laboratory studies (CBC, BMP, urinalysis, biopsy, immunohistochemistry), and imaging (ultrasound, CT, MRI, PET). Treatment includes monitoring and supportive care until a definitive diagnosis is made. Benign neoplasms may not require further treatment, while malignant ones might necessitate surgical excision, cystectomy, radiation, or chemotherapy.
In simple words: A tumor in your bladder that doctors can't currently tell if it's cancerous (malignant) or not (benign) based on initial tests.
Neoplasm of uncertain behavior of the urinary bladder. This diagnosis indicates a tumor in the bladder whose nature (benign or malignant) cannot be definitively determined based on current histologic examination.
Example 1: A patient presents with hematuria and pelvic pain. Biopsy results are inconclusive, leading to a diagnosis of D41.4. The patient is closely monitored, and repeat biopsies are planned., During a cystoscopy, a suspicious lesion is discovered in the bladder. Biopsy suggests a neoplasm, but the pathologist cannot definitively classify it as benign or malignant. D41.4 is assigned, and further investigation with immunohistochemical stains is ordered., A patient with a history of bladder cancer undergoes surveillance cystoscopy. A new lesion is biopsied, and the pathology report returns as "neoplasm of uncertain behavior." D41.4 is used while awaiting additional tests to determine the nature of the neoplasm.
Complete clinical documentation should include details of the patient's presenting symptoms, physical examination findings, results of imaging studies (e.g., cystoscopy, ultrasound, CT, MRI), and pathology reports from biopsies. If immunohistochemistry or other specialized tests are performed, their results should also be documented.
- Specialties:Urology, Oncology, Pathology
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Office