ICD-10 Code D26.1 | Other benign neoplasm of corpus uteri Symptoms, Diagnosis, Billing

Other benign neoplasm of the corpus uteri refers to non-cancerous tumors located in the uterine body. These neoplasms can arise from various tissues, including smooth muscle and connective tissue. Clinically significant due to potential symptoms such as abnormal bleeding or pressure effects, accurate coding with ICD-10 Code D26.1 ensures proper diagnosis, documentation, and billing, facilitating effective patient management and public health reporting.

What is ICD-10 Code D26.1 for Other benign neoplasm of corpus uteri?

ICD-10 Code D26.1 represents a diagnosis of other benign neoplasm of the corpus uteri. This code is used when a patient presents with non-cancerous growths in the uterine body, which may lead to symptoms such as abnormal uterine bleeding or pelvic discomfort. It is essential for accurate clinical documentation and billing, particularly when distinguishing from malignant conditions.

ICD-10 Code D26.1 – Clinical Definition and Explanation of Other benign neoplasm of corpus uteri

Other benign neoplasms of the corpus uteri can arise from various cellular origins, including smooth muscle (leiomyomas) and endometrial tissue. These growths may be asymptomatic or present with symptoms requiring medical evaluation. Prompt diagnosis is crucial to manage potential complications and ensure appropriate treatment.

Key Clinical Features:

• May present with abnormal uterine bleeding or pelvic pain.
• Typically diagnosed via imaging studies such as ultrasound or MRI.
• Can lead to complications like anemia due to heavy menstrual bleeding.
• More common in women of reproductive age, particularly those with a family history.

ICD-10 Code D26.1 for Other benign neoplasm of corpus uteri – SOAP Notes & Clinical Use

ICD-10 Code D26.1 is utilized in SOAP notes to document the presence of a benign neoplasm in the corpus uteri. It plays a vital role in capturing patient symptoms, guiding assessments, and outlining treatment plans, relevant in both acute and chronic care settings.

What Does ICD-10 Code D26.1 for Other benign neoplasm of corpus uteri Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D26.1 connects subjective reports of symptoms, such as abnormal bleeding, with objective findings from examinations or imaging. This formal diagnosis supports continuity of care, facilitates accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D26.1 – Other benign neoplasm of corpus uteri

Management of other benign neoplasms of the corpus uteri may require hospitalization if complications arise. Treatment approaches vary based on symptom severity and patient preference.

Antibiotic Therapy:

• Not applicable as this condition is not infectious.

Supportive Care:

• Pain management with NSAIDs as needed.
• Monitoring for changes in symptoms.
• Counseling on menstrual health and potential surgical options.

Infection Control:

• No specific infection control measures required for benign neoplasms.

How to Document Symptoms of Other benign neoplasm of corpus uteri (ICD-10 D26.1) in SOAP Notes

Subjective:

• Patient reports heavy menstrual bleeding for the past three months.
• Complains of pelvic pressure and discomfort.
• History of irregular menstrual cycles.
• No significant past medical or surgical history.

Objective:

• Vital signs stable; no fever.
• Pelvic examination reveals enlarged uterus.
• Transvaginal ultrasound shows a mass in the corpus uteri.
• Lab results indicate mild anemia.

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SOAP Note Guidelines for Diagnosing Other benign neoplasm of corpus uteri (ICD-10 Code D26.1)

Assessment:

• Diagnosis: Other benign neoplasm of corpus uteri, moderate severity.
• ICD-10 Code: D26.1.
• Contributing factors: Hormonal imbalances and family history.

Plan:

• Consider referral to gynecology for further evaluation.
• Discuss potential treatment options including watchful waiting or surgical intervention.
• Educate patient on signs of complications and when to seek immediate care.
• Schedule follow-up appointment in 4-6 weeks.

Treatment & Plan Section for ICD-10 Code D26.1 – Other benign neoplasm of corpus uteri

• First-line treatment may include hormonal therapy to manage symptoms.
• Surgical options such as myomectomy may be considered for significant symptoms.
• Regular monitoring of symptoms and uterine size through follow-up imaging.
• Patient education on lifestyle modifications to manage symptoms.

Using ICD-10 Code D26.1 for Other benign neoplasm of corpus uteri in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective and Objective sections.
• Use D26.1 when a benign neoplasm is confirmed through imaging or biopsy.
• Align treatment plans with clinical guidelines to support justified billing.
• Include relevant CPT codes for procedures performed in conjunction with the diagnosis.

Related ICD-10 Codes Often Used with Other benign neoplasm of corpus uteri

• D25.9 – Uterine leiomyoma, unspecified

ICD-10 Code D26.1 in Medical Billing and Insurance for Other benign neoplasm of corpus uteri

ICD-10 Code D26.1 is crucial for accurate billing in hospital, ER, or outpatient settings when managing benign neoplasms of the corpus uteri.

Billing Notes:

• Document all relevant clinical findings and patient history to support the diagnosis.
• Use D26.1 in conjunction with procedure codes for any surgical interventions.
• Ensure compliance with payer-specific guidelines for documentation and coding.

Common CPT Pairings: