ICD-10 Code D35.4 | Benign neoplasm of pineal gland Symptoms, Diagnosis, Billing

Benign neoplasm of the pineal gland is a non-cancerous tumor that arises from the cells of the pineal gland, which is responsible for melatonin production and regulation of circadian rhythms. These neoplasms can lead to symptoms such as headaches, visual disturbances, and hormonal imbalances. Accurate coding with ICD-10 Code D35.4 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code D35.4 for Benign neoplasm of pineal gland?

ICD-10 Code D35.4 specifically denotes a benign neoplasm of the pineal gland. This code is utilized when documenting cases of non-cancerous tumors in this region, which may cause various neurological and endocrine symptoms. It is important to use this code in clinical documentation and billing to ensure accurate representation of the patient's condition and to facilitate appropriate treatment and follow-up.

ICD-10 Code D35.4 – Clinical Definition and Explanation of Benign neoplasm of pineal gland

Benign neoplasms of the pineal gland are typically slow-growing tumors that can disrupt normal gland function and lead to various clinical symptoms. While the exact cause remains unclear, these tumors may arise from genetic mutations or environmental factors. Medical attention is crucial to monitor symptoms and prevent complications.

Key Clinical Features:

• Headaches, often worsening in severity or frequency.
• Visual disturbances, including blurred vision or double vision.
• Hormonal imbalances leading to changes in sleep patterns.
• Possible signs of increased intracranial pressure.

ICD-10 Code D35.4 for Benign neoplasm of pineal gland – SOAP Notes & Clinical Use

ICD-10 Code D35.4 is integral in SOAP notes for documenting the patient's symptoms, assessment findings, and treatment plans. This code aids in both acute and chronic care settings, ensuring that healthcare providers can track the patient's condition and response to treatment effectively.

What Does ICD-10 Code D35.4 for Benign neoplasm of pineal gland Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D35.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of benign neoplasm of the pineal gland. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D35.4 – Benign neoplasm of pineal gland

Management of benign neoplasms of the pineal gland may require hospitalization for monitoring and treatment. Surgical intervention is often the primary approach, depending on the tumor's size and symptoms.

Antibiotic Therapy:

Supportive Care:

• Pain management with analgesics as needed.
• Monitoring for neurological symptoms and intracranial pressure.
• Endocrine evaluation and management if hormonal imbalances occur.

Infection Control:

How to Document Symptoms of Benign neoplasm of pineal gland (ICD-10 D35.4) in SOAP Notes

Subjective:

• Patient reports persistent headaches, particularly in the morning.
• Complaints of blurred vision and occasional dizziness.
• History of sleep disturbances, including insomnia.
• No significant past medical history noted.

Objective:

• Neurological examination reveals mild papilledema.
• Visual acuity testing shows reduced clarity in both eyes.
• CT scan indicates a mass in the pineal region.
• Vital signs stable; no signs of acute distress.

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SOAP Note Guidelines for Diagnosing Benign neoplasm of pineal gland (ICD-10 Code D35.4)

Assessment:

• Diagnosis: Benign neoplasm of pineal gland, moderate severity.
• ICD-10 Code: D35.4.
• Contributing factors: Possible hormonal imbalance and increased intracranial pressure.
• Monitor for progression of symptoms.

Plan:

• Refer to neurosurgery for evaluation and potential resection.
• Schedule follow-up imaging to monitor tumor size.
• Educate patient on symptoms to watch for and when to seek immediate care.
• Arrange for endocrine consultation if hormonal symptoms persist.

Treatment & Plan Section for ICD-10 Code D35.4 – Benign neoplasm of pineal gland

• Consider surgical intervention for symptomatic relief.
• Implement regular follow-up imaging to assess tumor stability.
• Provide patient education on symptom management and lifestyle adjustments.
• Coordinate care with specialists as needed for comprehensive management.

Using ICD-10 Code D35.4 for Benign neoplasm of pineal gland in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use D35.4 in conjunction with relevant procedure codes for billing.
• Maintain clear records of treatment plans and follow-up care.
• Align treatment plans with clinical guidelines to support justified billing.

Related ICD-10 Codes Often Used with Benign neoplasm of pineal gland

• D35.3 – Benign neoplasm of other parts of the brain
• D32.0 – Benign neoplasm of meninges
• D33.0 – Benign neoplasm of spinal cord
• D35.2 – Benign neoplasm of pituitary gland

ICD-10 Code D35.4 in Medical Billing and Insurance for Benign neoplasm of pineal gland

ICD-10 Code D35.4 is crucial for accurate billing in hospital, ER, or specialty care settings, ensuring proper reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the claim.
• Use D35.4 in conjunction with procedure codes for surgical interventions.
• Ensure that all documentation aligns with payer requirements for reimbursement.
• Maintain thorough records of patient interactions and follow-up care.

Common CPT Pairings: