Coding, Classification and Reimbursement

Coding a renal cyst from an ancillary imaging report

  • 1.  Coding a renal cyst from an ancillary imaging report

    Posted 18 days ago
    ​​Hello all,

    Does anyone have information pointing to the correct ICD 10 code for a "renal cyst" with no other documentation?
    The index and the tabular make this confusing as they both use the same non essential modifiers.
    Your documentation states "there is a renal cyst on the left kidney, follow up with...." - -If you index the renal cyst,
    renal cyst
    and choose solitary(single) you get a congenital "Q" code. However if you default to the kidney (acquired) you get N28.1 that has non-essential modifiers of "Cyst (multiple) (solitary) of kidney (acquired)"
    N28

    I would really hate to query this diagnosis every time I see it for clarification, especially foreseeing an answer of "unable to determine" on those queries.

    Thoughts? Would you use the specificity of a single cyst and code the Q code? Would you default to acquired that includes the term single?

    sorry the pictures are fuzzy, not sure what happened there??

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    William Morriss
    Facility Reimbursement Speacialist
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  • 2.  RE: Coding a renal cyst from an ancillary imaging report

    Posted 17 days ago
    Hi William-

    N28.1 is the correct code (unless there is other documentation stating that this is congenital)

    In my opinion, the key piece of information is not the words solitary or multiple, but rather the words acquired or congenital.
    Only the congenital Q codes have more specificity for solitary or multiple.

    Hope that helps.

    -Katie

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    Kathryn O'Hearn, RHIA, CCS-P, CRC
    Provider Education Program Manager
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  • 3.  RE: Coding a renal cyst from an ancillary imaging report

    Posted 16 days ago
    ​Hello!

    I am glad you brought this up.  Using the actual Index, rather than the Encoder clarified things for me. When it comes to Cyst, Kidney the term "solitary" is an essential modifier.  If the term "solitary" is not documented, the Index does default to N28.1 for Kidney  cyst, NOS.  I would not issue any query for cases like this.

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    Lawrence Barr
    Coder 3
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