Malignant neoplasm of uterine adnexa, unspecified refers to cancerous growths located in the uterine adnexa, which includes the ovaries and fallopian tubes. This condition is clinically significant due to its potential for metastasis and impact on reproductive health. Accurate coding with ICD-10 Code C57.4 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 C57.4 for Malignant neoplasm of uterine adnexa, unspecified?
ICD-10 Code C57.4 represents malignant neoplasms of the uterine adnexa that are unspecified. This code is utilized when the specific site of the neoplasm within the adnexa is not documented. It is crucial for clinical documentation and billing, particularly when diagnosing patients with ovarian or fallopian tube cancers, ensuring appropriate treatment and resource allocation.
ICD-10 Code C57.4 – Clinical Definition and Explanation of Malignant neoplasm of uterine adnexa, unspecified
Malignant neoplasm of uterine adnexa, unspecified, is characterized by the uncontrolled growth of abnormal cells in the ovaries or fallopian tubes. The exact cause remains unclear, but risk factors include genetic predisposition, hormonal influences, and environmental factors. Prompt medical attention is necessary due to the potential for aggressive disease progression.
Key Clinical Features:
- Abdominal pain or discomfort
- Irregular menstrual bleeding
- Pelvic mass or swelling
- Unexplained weight loss
ICD-10 Code C57.4 for Malignant neoplasm of uterine adnexa, unspecified – SOAP Notes & Clinical Use
ICD-10 Code C57.4 is utilized in SOAP notes to document the presence of malignant neoplasms in the uterine adnexa. It plays a vital role in capturing patient symptoms, assessment findings, and treatment plans, relevant in both acute and chronic care settings.
What Does ICD-10 Code C57.4 for Malignant neoplasm of uterine adnexa, unspecified Mean in SOAP Notes?
In SOAP notes, ICD-10 Code C57.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of malignant neoplasm of the uterine adnexa. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code C57.4 – Malignant neoplasm of uterine adnexa, unspecified
The management of malignant neoplasm of uterine adnexa, unspecified, often necessitates hospitalization for comprehensive treatment. Surgical intervention, chemotherapy, or radiation therapy may be indicated based on the disease stage.
Antibiotic Therapy:
- Not applicable as this is not an infectious condition.
Supportive Care:
- Pain management with analgesics
- Nutritional support
- Psychosocial support services
Infection Control:
- Standard precautions during treatment
- Monitoring for signs of infection post-surgery
How to Document Symptoms of Malignant neoplasm of uterine adnexa, unspecified (ICD-10 C57.4) in SOAP Notes
Subjective:
- Patient reports persistent abdominal pain
- History of irregular menstrual cycles
- Noticed a pelvic mass during self-examination
- Experiencing unexplained fatigue
Objective:
- Abdominal tenderness on examination
- Pelvic ultrasound shows a mass in the adnexa
- Elevated CA-125 levels
- Weight loss of 10 pounds in the last month
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SOAP Note Guidelines for Diagnosing Malignant neoplasm of uterine adnexa, unspecified (ICD-10 Code C57.4)
Assessment:
- Diagnosis: Malignant neoplasm of uterine adnexa, unspecified, moderate severity
- ICD-10 Code: C57.4
- Contributing factors: Family history of ovarian cancer
- Patient's age and symptoms suggest advanced disease.
Plan:
- Refer to oncology for further evaluation and treatment
- Consider imaging studies for staging
- Educate patient on treatment options and potential side effects
- Schedule follow-up appointment in one month to reassess.
Treatment & Plan Section for ICD-10 Code C57.4 – Malignant neoplasm of uterine adnexa, unspecified
- Chemotherapy regimen based on tumor type and stage
- Surgical options including oophorectomy or hysterectomy
- Regular follow-up imaging to monitor treatment response
- Patient education on lifestyle modifications and support resources
Using ICD-10 Code C57.4 for Malignant neoplasm of uterine adnexa, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and findings in the Subjective (S) and Objective (O) sections
- Use C57.4 in conjunction with relevant CPT codes for procedures performed
- Maintain compliance with coding guidelines to support reimbursement
- Document treatment plans that align with clinical guidelines for justifiable billing.
Related ICD-10 Codes Often Used with Malignant neoplasm of uterine adnexa, unspecified
ICD-10 Code C57.4 in Medical Billing and Insurance for Malignant neoplasm of uterine adnexa, unspecified
ICD-10 Code C57.4 is critical in medical billing, particularly in hospital and ER settings, to ensure accurate claims for treatment of malignant neoplasms.
Billing Notes:
- Document all relevant clinical findings to support the diagnosis
- Use C57.4 in conjunction with procedure codes for surgical interventions
- Ensure that the medical necessity for treatment is clearly articulated in the notes
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 58150 | Total abdominal hysterectomy, with or without salpingo-oophorectomy |
| 96413 | Chemotherapy administration, intravenous, push technique, single or initial substance |
| 88305 | Pathology examination of tissue for malignancy |
Frequently Asked Questions
Common Questions About Using ICD-10 Code C57.4 for Malignant neoplasm of uterine adnexa, unspecified
What are the common symptoms of malignant neoplasm of uterine adnexa?
Common symptoms include abdominal pain, irregular menstrual bleeding, pelvic mass, and unexplained weight loss. Patients may also experience fatigue and changes in appetite.
How is the diagnosis of malignant neoplasm of uterine adnexa confirmed?
Diagnosis is typically confirmed through imaging studies such as ultrasound or CT scans, followed by biopsy of the mass to assess for malignancy.
What treatment options are available for this condition?
Treatment options may include surgical intervention, chemotherapy, and radiation therapy, depending on the stage and type of cancer.
Is hospitalization required for patients with this diagnosis?
Yes, hospitalization may be required for surgical procedures, chemotherapy administration, and monitoring for complications.
