ICD-10 Code C49.A5 | Gastrointestinal stromal tumor of rectum Symptoms, Diagnosis, Billing

Gastrointestinal stromal tumor (GIST) of the rectum is a rare neoplasm arising from interstitial cells of Cajal or precursor cells in the gastrointestinal tract. These tumors can be malignant and may lead to significant morbidity. Accurate coding with ICD-10 Code C49.A5 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code C49.A5 for Gastrointestinal stromal tumor of rectum?

ICD-10 Code C49.A5 specifically identifies gastrointestinal stromal tumors located in the rectum. These tumors are characterized by their origin from mesenchymal cells and can exhibit aggressive behavior. This code should be used in clinical documentation and billing when a patient is diagnosed with a GIST of the rectum, facilitating accurate treatment planning and reimbursement.

ICD-10 Code C49.A5 – Clinical Definition and Explanation of Gastrointestinal stromal tumor of rectum

Gastrointestinal stromal tumors of the rectum are rare tumors that arise from the connective tissue of the gastrointestinal tract. They are often associated with mutations in the KIT gene and can progress to malignancy if not treated. Prompt medical attention is crucial for effective management and to prevent complications.

Key Clinical Features:

• May present with rectal bleeding or obstruction.
• Can be asymptomatic in early stages.
• Histologically characterized by spindle or epithelioid cells.
• Often associated with mutations in the KIT or PDGFRA genes.

ICD-10 Code C49.A5 for Gastrointestinal stromal tumor of rectum – SOAP Notes & Clinical Use

ICD-10 Code C49.A5 is utilized in SOAP notes to document the presence of a gastrointestinal stromal tumor of the rectum. It 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 C49.A5 for Gastrointestinal stromal tumor of rectum Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C49.A5 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a gastrointestinal stromal tumor of the rectum. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code C49.A5 – Gastrointestinal stromal tumor of rectum

Management of gastrointestinal stromal tumors of the rectum often requires hospitalization for surgical intervention and may include targeted therapies. Early diagnosis and treatment are critical to improve outcomes.

Antibiotic Therapy:

Supportive Care:

• Pain management with analgesics.
• Nutritional support as needed.
• Monitoring for complications post-surgery.

Infection Control:

How to Document Symptoms of Gastrointestinal stromal tumor of rectum (ICD-10 C49.A5) in SOAP Notes

Subjective:

• Patient reports rectal bleeding.
• Complaints of abdominal pain.
• History of weight loss over the past month.
• No prior history of gastrointestinal tumors.

Objective:

• Abdominal tenderness on palpation.
• Rectal examination reveals a mass.
• Imaging shows a tumor in the rectal area.
• Vital signs stable.

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SOAP Note Guidelines for Diagnosing Gastrointestinal stromal tumor of rectum (ICD-10 Code C49.A5)

Assessment:

• Diagnosis: Gastrointestinal stromal tumor of rectum, malignant.
• ICD-10 Code: C49.A5.
• Contributing factors: Genetic mutations, possible familial syndromes.
• Severity: Moderate to high risk of metastasis.

Plan:

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

Treatment & Plan Section for ICD-10 Code C49.A5 – Gastrointestinal stromal tumor of rectum

• First-line treatment includes surgical resection of the tumor.
• Targeted therapy with imatinib may be indicated for unresectable tumors.
• Regular follow-up with imaging studies to monitor for recurrence.
• Patient education on symptom management and lifestyle modifications.

Using ICD-10 Code C49.A5 for Gastrointestinal stromal tumor of rectum in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and findings in the Subjective and Objective sections.
• Use C49.A5 in conjunction with relevant CPT codes for surgical procedures.
• Maintain compliance with coding guidelines to support reimbursement.
• Document treatment plans that align with clinical guidelines.

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

• C49.A0 – Gastrointestinal stromal tumor of small intestine
• C49.A1 – Gastrointestinal stromal tumor of colon
• C49.A2 – Gastrointestinal stromal tumor of stomach
• C49.A3 – Gastrointestinal stromal tumor of esophagus

ICD-10 Code C49.A5 in Medical Billing and Insurance for Gastrointestinal stromal tumor of rectum

ICD-10 Code C49.A5 is crucial for billing purposes, particularly in hospital and surgical settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of C49.A5.
• Ensure the code is used in appropriate settings, such as inpatient or outpatient surgical procedures.
• Include key elements in the chart, such as imaging results and treatment plans.

Common CPT Pairings: