ICD-10 Code D30.11 | Benign neoplasm of right renal pelvis Symptoms, Diagnosis, Billing

Benign neoplasm of the right renal pelvis refers to a non-cancerous tumor located in the renal pelvis, which is the area of the kidney where urine collects before moving to the ureter. These neoplasms can arise from various cell types and may be asymptomatic or present with symptoms such as hematuria or flank pain. Accurate coding with ICD-10 Code D30.11 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage this condition.

What is ICD-10 Code D30.11 for Benign neoplasm of right renal pelvis?

ICD-10 Code D30.11 specifically identifies a benign neoplasm located in the right renal pelvis. This code is utilized when documenting cases of non-cancerous tumors in this area, which may lead to complications such as obstruction or infection. It is important to use this code in clinical documentation and billing when a patient is diagnosed with this condition to ensure accurate representation of the patient's health status and treatment needs.

ICD-10 Code D30.11 – Clinical Definition and Explanation of Benign neoplasm of right renal pelvis

Benign neoplasms of the right renal pelvis can arise from various tissues, including epithelial and connective tissues. While often asymptomatic, they may cause complications that necessitate medical evaluation and intervention. Prompt diagnosis and management are crucial to prevent potential complications such as urinary obstruction.

Key Clinical Features:

• Asymptomatic in many cases
• Possible hematuria (blood in urine)
• Flank pain or discomfort
• Potential for urinary obstruction
• Incidental finding on imaging studies

ICD-10 Code D30.11 for Benign neoplasm of right renal pelvis – SOAP Notes & Clinical Use

ICD-10 Code D30.11 is utilized in SOAP notes to document the presence of a benign neoplasm in the right renal pelvis. This code aids in capturing the patient's symptoms, assessment findings, and treatment plans, ensuring comprehensive documentation in both acute and chronic care settings.

What Does ICD-10 Code D30.11 for Benign neoplasm of right renal pelvis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D30.11 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a benign neoplasm in the right renal pelvis. This coding ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D30.11 – Benign neoplasm of right renal pelvis

Management of benign neoplasms of the right renal pelvis may vary based on symptoms and complications. Surgical intervention is often considered if the neoplasm causes significant issues.

Antibiotic Therapy:

• Not typically indicated unless secondary infection occurs.
• Consideration for prophylactic antibiotics if surgery is planned.
• Duration of therapy based on clinical judgment.

Supportive Care:

• Pain management with analgesics as needed.
• Monitoring for urinary symptoms or complications.
• Regular follow-up imaging to assess for changes.

Infection Control:

• Standard precautions during any invasive procedures.
• Monitoring for signs of urinary tract infection post-surgery.
• Patient education on hygiene and symptom awareness.

How to Document Symptoms of Benign neoplasm of right renal pelvis (ICD-10 D30.11) in SOAP Notes

Subjective:

• Patient reports intermittent flank pain.
• No history of hematuria noted.
• Denies fever or chills.
• No previous urinary tract infections.

Objective:

• Physical examination reveals tenderness in the right flank.
• Imaging shows a mass in the right renal pelvis.
• Urinalysis is negative for infection.
• Vital signs within normal limits.

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SOAP Note Guidelines for Diagnosing Benign neoplasm of right renal pelvis (ICD-10 Code D30.11)

Assessment:

• Diagnosis: Benign neoplasm of right renal pelvis, asymptomatic.
• ICD-10 Code: D30.11.
• No significant contributing factors identified.
• Monitor for potential complications.

Plan:

• Consider referral to urology for evaluation.
• Educate patient on signs of complications.
• Schedule follow-up imaging in 6 months.
• Monitor renal function and symptoms.

Treatment & Plan Section for ICD-10 Code D30.11 – Benign neoplasm of right renal pelvis

• Surgical intervention if symptomatic or obstructive.
• Regular imaging to monitor for growth or complications.
• Patient education on symptom management and when to seek care.
• Follow-up appointments to assess renal function and overall health.

Using ICD-10 Code D30.11 for Benign neoplasm of right renal pelvis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and findings in SOAP notes.
• Use D30.11 for billing when the diagnosis is confirmed.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Benign neoplasm of right renal pelvis

• D30.12 – Benign neoplasm of left renal pelvis
• D30.9 – Benign neoplasm of unspecified renal pelvis

ICD-10 Code D30.11 in Medical Billing and Insurance for Benign neoplasm of right renal pelvis

ICD-10 Code D30.11 is critical for accurate billing in hospital, ER, or outpatient settings, ensuring that the diagnosis of a benign neoplasm is properly documented for reimbursement.

Billing Notes:

• Document all relevant patient history and clinical findings clearly.
• Use D30.11 in conjunction with appropriate CPT codes for services rendered.
• Ensure compliance with payer guidelines for coding and billing.
• Review documentation for completeness before submission.

Common CPT Pairings: