ICD-10 Code D13.91 | Familial adenomatous polyposis Symptoms, Diagnosis, Billing

Familial adenomatous polyposis is a hereditary condition characterized by the development of numerous polyps in the colon and rectum, significantly increasing the risk of colorectal cancer. The condition is caused by mutations in the APC gene. Accurate coding with ICD-10 Code D13.91 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate surveillance and management.

What is ICD-10 Code D13.91 for Familial adenomatous polyposis?

ICD-10 Code D13.91 represents familial adenomatous polyposis, a genetic disorder leading to the formation of multiple adenomatous polyps in the gastrointestinal tract. This code should be used in clinical documentation and billing when diagnosing patients with this hereditary condition, which necessitates regular monitoring and potential surgical intervention to prevent colorectal cancer.

ICD-10 Code D13.91 – Clinical Definition and Explanation of Familial adenomatous polyposis

Familial adenomatous polyposis is primarily caused by mutations in the APC gene, leading to the development of hundreds to thousands of polyps in the colon, typically starting in adolescence or early adulthood. Without intervention, nearly all individuals with this condition will develop colorectal cancer by age 40. Early diagnosis and management are crucial to prevent malignancy.

Key Clinical Features:

• Presence of multiple adenomatous polyps in the colon and rectum.
• Family history of colorectal cancer or polyposis.
• Symptoms may include rectal bleeding, abdominal pain, and changes in bowel habits.
• Increased risk of extracolonic cancers, including duodenal and thyroid cancers.

ICD-10 Code D13.91 for Familial adenomatous polyposis – SOAP Notes & Clinical Use

ICD-10 Code D13.91 is utilized in SOAP notes to document the diagnosis of familial adenomatous polyposis, guiding clinical assessment and treatment planning. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management strategies.

What Does ICD-10 Code D13.91 for Familial adenomatous polyposis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D13.91 connects subjective patient reports and objective clinical findings to a formal diagnosis of familial adenomatous polyposis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D13.91 – Familial adenomatous polyposis

Familial adenomatous polyposis requires proactive management to prevent colorectal cancer. Treatment typically involves regular surveillance and may necessitate surgical intervention.

Antibiotic Therapy:

Supportive Care:

• Regular colonoscopic surveillance starting in adolescence.
• Consideration of prophylactic colectomy to prevent cancer.
• Genetic counseling for affected individuals and family members.

Infection Control:

How to Document Symptoms of Familial adenomatous polyposis (ICD-10 D13.91) in SOAP Notes

Subjective:

• Patient reports a family history of colorectal cancer.
• Complaints of intermittent abdominal pain.
• Noted changes in bowel habits over the past few months.
• Experiencing rectal bleeding occasionally.

Objective:

• Physical examination reveals tenderness in the lower abdomen.
• Colonoscopy shows numerous adenomatous polyps.
• Biopsy confirms the presence of dysplastic polyps.
• No signs of acute distress noted during examination.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Familial adenomatous polyposis (ICD-10 Code D13.91)

Assessment:

• Diagnosis of familial adenomatous polyposis (ICD-10 D13.91).
• Severity classified as high risk for colorectal cancer.
• Family history of colorectal cancer noted as a contributing factor.
• Patient education on the importance of surveillance and management.

Plan:

• Schedule regular colonoscopic surveillance every 1-2 years.
• Discuss the option of prophylactic colectomy with the patient.
• Provide genetic counseling resources for the patient and family.
• Monitor for any new symptoms or changes in health status.

Treatment & Plan Section for ICD-10 Code D13.91 – Familial adenomatous polyposis

• Regular colonoscopic surveillance to monitor polyp development.
• Consideration of prophylactic colectomy to reduce cancer risk.
• Patient education on lifestyle modifications to support gastrointestinal health.
• Referral to genetic counseling for family members at risk.

Using ICD-10 Code D13.91 for Familial adenomatous polyposis in Billing & SOAP Note Compliance

• Ensure accurate documentation of family history and clinical findings in SOAP notes.
• Use D13.91 in conjunction with relevant procedure codes for colonoscopy and surgical interventions.
• Document patient education and management plans to support billing.
• Maintain compliance with coding guidelines to ensure proper reimbursement.

Related ICD-10 Codes Often Used with Familial adenomatous polyposis

• D12.6 – Benign neoplasm of colon, unspecified
• C18.9 – Malignant neoplasm of colon, unspecified

ICD-10 Code D13.91 in Medical Billing and Insurance for Familial adenomatous polyposis

ICD-10 Code D13.91 is critical in medical billing, particularly in hospital and outpatient settings, to ensure accurate reimbursement for services related to familial adenomatous polyposis.

Billing Notes:

• Document all relevant clinical findings and family history to support the use of D13.91.
• Use this code in conjunction with procedure codes for colonoscopy and surgical interventions.
• Ensure that patient education and management plans are clearly documented.
• Review coding guidelines regularly to maintain compliance.

Common CPT Pairings: