ICD-10 Code D26.9 | Other benign neoplasm of uterus, unspecified Symptoms, Diagnosis, Billing

Other benign neoplasm of the uterus, unspecified, refers to non-cancerous tumors that arise in the uterine tissue. These neoplasms can vary in size and may cause symptoms such as abnormal bleeding or pelvic pain. Accurate coding with ICD-10 Code D26.9 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage these conditions effectively.

What is ICD-10 Code D26.9 for Other benign neoplasm of uterus, unspecified?

ICD-10 Code D26.9 represents a diagnosis of other benign neoplasm of the uterus that is unspecified. This code is used when a patient presents with a benign tumor in the uterus, but the specific type or characteristics of the neoplasm are not clearly defined. It is important for clinical documentation and billing to accurately reflect the patient's condition, ensuring appropriate treatment and follow-up.

ICD-10 Code D26.9 – Clinical Definition and Explanation of Other benign neoplasm of uterus, unspecified

Other benign neoplasms of the uterus can arise from various tissues, including smooth muscle and connective tissue. These growths are typically non-cancerous but may lead to complications such as pain or bleeding, necessitating medical evaluation. Prompt diagnosis and management are crucial to prevent potential complications.

Key Clinical Features:

• May present with abnormal uterine bleeding or pelvic discomfort.
• Typically non-cancerous but can cause significant symptoms.
• Diagnosis often confirmed through imaging studies or biopsy.
• Common in women of reproductive age, but can occur at any age.

ICD-10 Code D26.9 for Other benign neoplasm of uterus, unspecified – SOAP Notes & Clinical Use

ICD-10 Code D26.9 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. This code aids in capturing the clinical picture of the patient, ensuring that both acute and chronic care settings can address the condition effectively.

What Does ICD-10 Code D26.9 for Other benign neoplasm of uterus, unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D26.9 connects subjective patient-reported symptoms with objective clinical findings, leading to a formal diagnosis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting electronic health record documentation standards.

Treatment Options for ICD-10 Code D26.9 – Other benign neoplasm of uterus, unspecified

Management of other benign neoplasms of the uterus may vary based on symptoms and patient preferences. While surgical intervention may be necessary in some cases, conservative management is often appropriate.

Antibiotic Therapy:

Supportive Care:

• Pain management with NSAIDs as needed.
• Monitoring for changes in symptoms or tumor size.
• Patient education on signs of complications.

Infection Control:

How to Document Symptoms of Other benign neoplasm of uterus, unspecified (ICD-10 D26.9) in SOAP Notes

Subjective:

• Patient reports intermittent pelvic pain.
• History of abnormal menstrual bleeding.
• No significant weight loss or systemic symptoms.
• Denies fever or other acute symptoms.

Objective:

• Pelvic examination reveals tenderness in the uterine area.
• Ultrasound shows a mass in the uterus.
• Vital signs stable with no abnormalities.
• Laboratory tests within normal limits.

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SOAP Note Guidelines for Diagnosing Other benign neoplasm of uterus, unspecified (ICD-10 Code D26.9)

Assessment:

• Diagnosis: Other benign neoplasm of uterus, unspecified (ICD-10 D26.9).
• Severity: Mild to moderate based on symptomatology.
• Contributing factors: Hormonal influences and genetic predisposition.
• No evidence of malignancy noted on imaging.

Plan:

• Consider referral to gynecology for further evaluation.
• Discuss potential surgical options if symptoms persist.
• Schedule follow-up in 6 weeks to reassess symptoms.
• Educate patient on monitoring for changes in symptoms.

Treatment & Plan Section for ICD-10 Code D26.9 – Other benign neoplasm of uterus, unspecified

• First-line treatment may include observation and symptom management.
• Surgical options such as myomectomy may be considered for symptomatic relief.
• Patient education on lifestyle modifications to manage symptoms.
• Regular follow-up appointments to monitor for changes in condition.

Using ICD-10 Code D26.9 for Other benign neoplasm of uterus, unspecified in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use D26.9 when the specific type of neoplasm is not identified.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Other benign neoplasm of uterus, unspecified

• D25.9 – Uterine leiomyoma, unspecified
• D26.0 – Benign neoplasm of uterus, subserosal
• D26.1 – Benign neoplasm of uterus, intramural

ICD-10 Code D26.9 in Medical Billing and Insurance for Other benign neoplasm of uterus, unspecified

ICD-10 Code D26.9 is crucial for accurate billing in hospital, emergency room, or outpatient settings, ensuring that the diagnosis is clearly communicated for reimbursement purposes.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use D26.9 in cases where the specific type of neoplasm is not specified.
• Ensure that the medical necessity for services is clearly outlined in the documentation.
• Include patient history and treatment plans to justify billing.

Common CPT Pairings: