ICD-10 Code C49.A3 | Gastrointestinal stromal tumor of small intestine Symptoms, Diagnosis, Billing

Gastrointestinal stromal tumors (GISTs) are rare tumors that arise from interstitial cells of Cajal or precursor cells in the gastrointestinal tract, particularly the small intestine. These tumors can be benign or malignant and are characterized by mutations in the KIT or PDGFRA genes. Accurate coding with ICD-10 Code C49.A3 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 C49.A3 for Gastrointestinal stromal tumor of small intestine?

ICD-10 Code C49.A3 specifically denotes a gastrointestinal stromal tumor located in the small intestine. This code is utilized when documenting cases of GISTs, which may present with symptoms such as abdominal pain, gastrointestinal bleeding, or obstruction. It is crucial for accurate clinical documentation and billing, particularly in oncology and surgical settings.

ICD-10 Code C49.A3 – Clinical Definition and Explanation of Gastrointestinal stromal tumor of small intestine

Gastrointestinal stromal tumors of the small intestine are neoplasms that can lead to significant morbidity if not diagnosed and treated promptly. These tumors often arise sporadically and may progress to metastatic disease, necessitating timely medical intervention.

Key Clinical Features:

• Abdominal pain or discomfort
• Gastrointestinal bleeding or anemia
• Palpable abdominal mass
• Nausea or vomiting

ICD-10 Code C49.A3 for Gastrointestinal stromal tumor of small intestine – SOAP Notes & Clinical Use

ICD-10 Code C49.A3 is integral to SOAP notes, facilitating the documentation of symptoms, assessments, and treatment plans for patients with gastrointestinal stromal tumors. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code C49.A3 for Gastrointestinal stromal tumor of small intestine Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C49.A3 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of gastrointestinal stromal tumor. This linkage is vital for continuity of care, supporting accurate billing and compliance with EHR documentation standards.

Treatment Options for ICD-10 Code C49.A3 – Gastrointestinal stromal tumor of small intestine

The management of gastrointestinal stromal tumors often requires hospitalization for surgical intervention or targeted therapy. Treatment approaches are tailored to the tumor's size, location, and metastatic potential.

Antibiotic Therapy:

• Not applicable as GISTs are not infectious; focus on surgical and pharmacologic treatments.

Supportive Care:

• Pain management strategies
• Nutritional support
• Monitoring for complications such as bleeding

Infection Control:

• Standard precautions during hospitalization
• Monitoring for postoperative infections

How to Document Symptoms of Gastrointestinal stromal tumor of small intestine (ICD-10 C49.A3) in SOAP Notes

Subjective:

• Patient reports intermittent abdominal pain over the past month.
• History of gastrointestinal bleeding with melena.
• Complaints of early satiety and weight loss.
• No prior history of similar symptoms.

Objective:

• Abdominal examination reveals a palpable mass in the right upper quadrant.
• Vital signs stable; no signs of acute distress.
• Laboratory tests show anemia with low hemoglobin levels.
• Imaging studies indicate a mass in the small intestine.

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SOAP Note Guidelines for Diagnosing Gastrointestinal stromal tumor of small intestine (ICD-10 Code C49.A3)

Assessment:

• Diagnosis: Gastrointestinal stromal tumor of small intestine, suspected malignant.
• ICD-10 Code: C49.A3.
• Contributing factors: Genetic mutations (KIT/PDGFRA), previous abdominal surgeries.
• Severity: Moderate to high risk of metastasis.

Plan:

• Refer for surgical evaluation and possible resection.
• Consider imatinib therapy for unresectable tumors.
• Educate patient on signs of complications and follow-up care.
• Schedule follow-up imaging to monitor tumor response.

Treatment & Plan Section for ICD-10 Code C49.A3 – Gastrointestinal stromal tumor of small intestine

• First-line treatment includes surgical resection of localized tumors.
• Imatinib (Gleevec) is indicated for unresectable or metastatic GISTs.
• Regular follow-up with imaging studies to assess treatment response.
• Patient education on dietary modifications and symptom management.

Using ICD-10 Code C49.A3 for Gastrointestinal stromal tumor of small intestine in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use C49.A3 in conjunction with relevant CPT codes for surgical procedures.
• Maintain compliance with coding guidelines to support reimbursement.
• Document all treatment plans and follow-up recommendations clearly.

Related ICD-10 Codes Often Used with Gastrointestinal stromal tumor of small intestine

• C49.A0 – Gastrointestinal stromal tumor of unspecified site

ICD-10 Code C49.A3 in Medical Billing and Insurance for Gastrointestinal stromal tumor of small intestine

ICD-10 Code C49.A3 is critical for accurate billing in hospital, ER, or oncology settings, ensuring proper reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the claim.
• Use C49.A3 in conjunction with appropriate CPT codes for surgical and medical interventions.
• Ensure that documentation reflects the severity and complexity of the case.
• Review coding guidelines regularly to maintain compliance.

Common CPT Pairings: