ICD-10 Code C38.4 | Malignant neoplasm of pleura Symptoms, Diagnosis, Billing

Malignant neoplasm of pleura refers to cancerous growths that originate in the pleura, the membrane surrounding the lungs. This condition is often associated with exposure to asbestos and can lead to significant respiratory complications. Accurate coding with ICD-10 Code C38.4 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track incidence and manage treatment effectively.

What is ICD-10 Code C38.4 for Malignant neoplasm of pleura?

ICD-10 Code C38.4 represents malignant neoplasm of the pleura, indicating the presence of cancerous cells in the pleural lining. This code is used when documenting cases of pleural malignancy, which may arise from primary pleural tumors or metastasis from other cancers. It is crucial for accurate clinical documentation and billing, particularly in oncology and respiratory care settings.

ICD-10 Code C38.4 – Clinical Definition and Explanation of Malignant neoplasm of pleura

Malignant neoplasm of pleura is primarily caused by asbestos exposure, leading to conditions such as mesothelioma. The disease progresses with symptoms like chest pain, dyspnea, and pleuritic pain, necessitating prompt medical evaluation and intervention.

Key Clinical Features:

• Chest pain or discomfort, often worsening with deep breathing.
• Shortness of breath due to pleural effusion or tumor mass.
• Cough, which may be persistent and unresponsive to treatment.
• Weight loss and fatigue as systemic symptoms of malignancy.

ICD-10 Code C38.4 for Malignant neoplasm of pleura – SOAP Notes & Clinical Use

ICD-10 Code C38.4 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to malignant pleural neoplasms. This code is relevant in both acute and chronic care settings, facilitating comprehensive patient management.

What Does ICD-10 Code C38.4 for Malignant neoplasm of pleura Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C38.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of malignant pleural neoplasm. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code C38.4 – Malignant neoplasm of pleura

Management of malignant neoplasm of pleura often requires hospitalization due to the complexity of treatment and potential complications.

Antibiotic Therapy:

• Not applicable as this condition is not infectious.

Supportive Care:

• Pain management with analgesics.
• Oxygen therapy for respiratory distress.
• Palliative care services for symptom management.

Infection Control:

• Standard precautions to prevent infection in immunocompromised patients.

How to Document Symptoms of Malignant neoplasm of pleura (ICD-10 C38.4) in SOAP Notes

Subjective:

• Patient reports persistent chest pain, worsening over the past month.
• Experiencing increasing shortness of breath, especially with exertion.
• Notable weight loss of 10 pounds in the last two months.
• History of asbestos exposure noted.

Objective:

• Auscultation reveals decreased breath sounds on the affected side.
• Chest X-ray shows pleural effusion.
• Vital signs: BP 120/80, HR 88, RR 22, SpO2 92% on room air.
• Physical exam reveals dullness to percussion over the left lung base.

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SOAP Note Guidelines for Diagnosing Malignant neoplasm of pleura (ICD-10 Code C38.4)

Assessment:

• Diagnosis: Malignant neoplasm of pleura (C38.4), likely mesothelioma.
• Severity: Advanced stage with significant respiratory compromise.
• Contributing factors: History of asbestos exposure.

Plan:

• Refer to oncology for evaluation and treatment options.
• Initiate palliative care for symptom management.
• Schedule follow-up imaging to assess pleural effusion.
• Educate patient on signs of respiratory distress and when to seek immediate care.

Treatment & Plan Section for ICD-10 Code C38.4 – Malignant neoplasm of pleura

• Consider chemotherapy or radiation therapy based on oncologist's recommendation.
• Implement lifestyle modifications to support overall health.
• Regular monitoring of respiratory function and symptom progression.
• Follow-up appointments to reassess treatment efficacy and adjust as needed.

Using ICD-10 Code C38.4 for Malignant neoplasm of pleura in Billing & SOAP Note Compliance

• Ensure clear documentation of symptoms and clinical findings under Subjective (S) and Objective (O).
• Use C38.4 in conjunction with appropriate CPT codes for oncology services.
• Maintain compliance with clinical guidelines to support justified billing.
• Document all treatment plans and patient education efforts thoroughly.

Related ICD-10 Codes Often Used with Malignant neoplasm of pleura

ICD-10 Code C38.4 in Medical Billing and Insurance for Malignant neoplasm of pleura

ICD-10 Code C38.4 is critical for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the claim.
• Use C38.4 in appropriate settings, including inpatient and outpatient oncology services.
• Ensure that all chart elements align with coding guidelines for compliance.

Common CPT Pairings: