ICD-10 Code D13.4 | Benign neoplasm of liver Symptoms, Diagnosis, Billing

Benign neoplasm of the liver refers to non-cancerous tumors that can arise in the liver tissue. These neoplasms may be asymptomatic or cause mild symptoms, but they are clinically significant due to their potential to cause complications such as obstruction or discomfort. Accurate coding with ICD-10 Code D13.4 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and monitor this condition.

What is ICD-10 Code D13.4 for Benign neoplasm of liver?

ICD-10 Code D13.4 specifically represents benign neoplasms of the liver. These tumors can include hepatic adenomas and focal nodular hyperplasia, which are generally non-malignant. This code should be used in clinical documentation and billing when a patient is diagnosed with a benign liver tumor, ensuring accurate representation of the patient's condition for treatment planning and reimbursement purposes.

ICD-10 Code D13.4 – Clinical Definition and Explanation of Benign neoplasm of liver

Benign neoplasms of the liver are typically caused by abnormal growth of liver cells, which can occur due to various factors, including hormonal influences and genetic predispositions. While these tumors are non-cancerous, they may require medical attention if they lead to symptoms or complications. Regular monitoring and assessment are crucial to manage any potential risks associated with these neoplasms.

Key Clinical Features:

• Asymptomatic in many cases, but may present with abdominal pain or discomfort.
• Can be detected incidentally during imaging studies for other conditions.
• May cause complications such as hemorrhage or obstruction if large.
• Commonly seen in young women, particularly those on hormonal therapy.

ICD-10 Code D13.4 for Benign neoplasm of liver – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code D13.4 is utilized to document the presence of a benign liver neoplasm, aiding in the assessment of symptoms, diagnostic findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management.

What Does ICD-10 Code D13.4 for Benign neoplasm of liver Mean in SOAP Notes?

ICD-10 Code D13.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a benign liver neoplasm. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D13.4 – Benign neoplasm of liver

Management of benign neoplasms of the liver may vary based on the size and symptoms of the tumor. While many cases may not require immediate intervention, monitoring and supportive care are essential.

Antibiotic Therapy:

Supportive Care:

• Regular imaging follow-ups to monitor tumor size and symptoms.
• Pain management strategies if the patient experiences discomfort.
• Patient education regarding signs of complications.

Infection Control:

How to Document Symptoms of Benign neoplasm of liver (ICD-10 D13.4) in SOAP Notes

Subjective:

• Patient reports intermittent abdominal pain localized to the right upper quadrant.
• No history of jaundice or significant weight loss.
• Denies nausea or vomiting.
• Patient is aware of a previous imaging study showing a liver mass.

Objective:

• Abdominal examination reveals mild tenderness in the right upper quadrant.
• No hepatomegaly or splenomegaly noted on palpation.
• Imaging studies confirm the presence of a benign liver neoplasm.

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SOAP Note Guidelines for Diagnosing Benign neoplasm of liver (ICD-10 Code D13.4)

Assessment:

• Diagnosis: Benign neoplasm of liver (ICD-10 Code D13.4).
• Severity: Mild, asymptomatic with no immediate complications.
• Contributing factors: Hormonal therapy history.
• Monitoring recommended due to potential for growth.

Plan:

• Schedule follow-up imaging in 6 months to monitor tumor size.
• Educate patient on symptoms that warrant immediate medical attention.
• Consider referral to a specialist if symptoms worsen.
• Document findings and update care plan as necessary.

Treatment & Plan Section for ICD-10 Code D13.4 – Benign neoplasm of liver

• Regular imaging follow-ups to assess tumor stability.
• Symptomatic treatment for abdominal discomfort as needed.
• Patient education on recognizing signs of complications.
• Referral to a hepatologist for specialized management if indicated.

Using ICD-10 Code D13.4 for Benign neoplasm of liver in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use D13.4 in conjunction with any relevant procedure codes for billing.
• Maintain compliance with coding guidelines to support reimbursement.
• Document any changes in the patient's condition to justify ongoing care.

Related ICD-10 Codes Often Used with Benign neoplasm of liver

• D13.0 – Benign neoplasm of liver, unspecified
• D13.1 – Benign neoplasm of liver, adenoma
• D13.2 – Benign neoplasm of liver, focal nodular hyperplasia

ICD-10 Code D13.4 in Medical Billing and Insurance for Benign neoplasm of liver

ICD-10 Code D13.4 is crucial for accurate billing in hospital, ER, or outpatient settings, ensuring proper reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings and patient history to support the use of D13.4.
• Use this code in conjunction with procedure codes for imaging or surgical interventions.
• Ensure that all documentation aligns with coding guidelines to avoid claim denials.
• Maintain clear records of follow-up care and patient education efforts.

Common CPT Pairings: