ICD-10 Code C55 | Malignant neoplasm of uterus, part unspecified Symptoms, Diagnosis, Billing

Malignant neoplasm of the uterus, part unspecified, refers to a cancerous growth located in the uterus where the specific part affected is not identified. This condition can arise from various factors, including genetic predisposition, hormonal influences, and environmental exposures. Accurate coding with ICD-10 Code C55 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this serious condition effectively.

What is ICD-10 Code C55 for Malignant neoplasm of uterus, part unspecified?

ICD-10 Code C55 designates malignant neoplasm of the uterus, part unspecified, indicating a cancerous tumor in the uterus without specifying the exact location. This code is utilized in clinical documentation and billing when a patient presents with uterine cancer symptoms, but the precise site of the tumor is not determined. It is crucial for accurate coding to facilitate appropriate treatment and reimbursement.

ICD-10 Code C55 – Clinical Definition and Explanation of Malignant neoplasm of uterus, part unspecified

Malignant neoplasm of the uterus, part unspecified, is characterized by uncontrolled cell growth in the uterine tissue, which can lead to significant morbidity and mortality if not addressed promptly. The condition may progress silently, necessitating vigilant screening and diagnostic measures.

Key Clinical Features:

• Abnormal vaginal bleeding or discharge
• Pelvic pain or pressure
• Unexplained weight loss
• Changes in menstrual cycle

ICD-10 Code C55 for Malignant neoplasm of uterus, part unspecified – SOAP Notes & Clinical Use

ICD-10 Code C55 is integral in SOAP notes for documenting the patient's symptoms, assessment findings, and treatment plans related to malignant neoplasm of the uterus. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code C55 for Malignant neoplasm of uterus, part unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C55 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of malignant neoplasm of the uterus, part unspecified. This coding supports continuity of care, facilitates billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code C55 – Malignant neoplasm of uterus, part unspecified

The management of malignant neoplasm of the uterus, part unspecified, often requires urgent intervention, including surgical and oncological therapies.

Antibiotic Therapy:

Supportive Care:

• Pain management with analgesics
• Nutritional support to maintain strength
• Psychosocial support for emotional well-being

Infection Control:

How to Document Symptoms of Malignant neoplasm of uterus, part unspecified (ICD-10 C55) in SOAP Notes

Subjective:

• Patient reports abnormal vaginal bleeding for the past month.
• History of pelvic pain that has worsened over the last few weeks.
• Unexplained weight loss of 10 pounds in the last two months.
• Patient expresses concern about changes in menstrual cycle.

Objective:

• Vital signs: BP 120/80 mmHg, HR 78 bpm, Temp 98.6°F.
• Pelvic examination reveals tenderness in the lower abdomen.
• Transvaginal ultrasound shows a mass in the uterus.
• Lab results indicate elevated tumor markers.

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SOAP Note Guidelines for Diagnosing Malignant neoplasm of uterus, part unspecified (ICD-10 Code C55)

Assessment:

• Diagnosis: Malignant neoplasm of uterus, part unspecified, moderate severity.
• ICD-10 Code: C55.
• Contributing factors: Age, family history of gynecological cancers.
• Patient presents with significant symptoms requiring further evaluation.

Plan:

• Refer to oncology for further evaluation and treatment options.
• Consider imaging studies for staging.
• Educate the patient on potential treatment pathways.
• Schedule follow-up appointment in two weeks.

Treatment & Plan Section for ICD-10 Code C55 – Malignant neoplasm of uterus, part unspecified

• Initiate referral to gynecologic oncology for surgical evaluation.
• Discuss potential chemotherapy or radiation therapy options.
• Provide education on symptom management and support resources.
• Monitor for side effects and response to treatment.

Using ICD-10 Code C55 for Malignant neoplasm of uterus, part unspecified in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use C55 for billing when the diagnosis is confirmed but the specific site is unspecified.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any relevant comorbidities or complications.

Related ICD-10 Codes Often Used with Malignant neoplasm of uterus, part unspecified

• C54.9 – Malignant neoplasm of uterus, part unspecified
• C51.9 – Malignant neoplasm of vulva, unspecified
• C56.9 – Malignant neoplasm of ovary, unspecified

ICD-10 Code C55 in Medical Billing and Insurance for Malignant neoplasm of uterus, part unspecified

ICD-10 Code C55 is critical in medical billing, particularly in hospital and emergency care settings, ensuring accurate claims processing.

Billing Notes:

• Document all relevant clinical findings and patient history to support the use of C55.
• Use C55 in conjunction with other codes for comprehensive billing.
• Ensure that the diagnosis is clearly linked to the treatment provided.
• Review payer-specific guidelines for documentation requirements.

Common CPT Pairings: