ICD-10 Code D39.11 | Neoplasm of uncertain behavior of right ovary Symptoms, Diagnosis, Billing

Neoplasm of uncertain behavior of the right ovary refers to a growth that may be benign or malignant but cannot be definitively classified. This condition is clinically significant as it necessitates careful monitoring and potential intervention. The ICD-10 Code D39.11 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this condition effectively.

What is ICD-10 Code D39.11 for Neoplasm of uncertain behavior of right ovary?

ICD-10 Code D39.11 represents a neoplasm of uncertain behavior located in the right ovary. This code is used when the nature of the tumor is indeterminate, requiring further evaluation to determine its potential malignancy. It is essential for clinical documentation and billing when a patient presents with ovarian masses that cannot be classified as benign or malignant at the time of diagnosis.

ICD-10 Code D39.11 – Clinical Definition and Explanation of Neoplasm of uncertain behavior of right ovary

Neoplasm of uncertain behavior of the right ovary can arise from various cellular origins and may progress unpredictably. It requires medical attention due to the potential for malignancy and the need for further diagnostic evaluation. Early identification and monitoring are crucial for patient management.

Key Clinical Features:

• Presence of an ovarian mass detected via imaging.
• Symptoms may include abdominal pain or discomfort.
• Potential for hormonal imbalances leading to menstrual irregularities.
• Need for follow-up imaging or biopsy to assess behavior.

ICD-10 Code D39.11 for Neoplasm of uncertain behavior of right ovary – SOAP Notes & Clinical Use

ICD-10 Code D39.11 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to the neoplasm of uncertain behavior of the right ovary. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code D39.11 for Neoplasm of uncertain behavior of right ovary Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D39.11 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D39.11 – Neoplasm of uncertain behavior of right ovary

Management of neoplasm of uncertain behavior of the right ovary may require hospitalization for further evaluation and treatment.

Antibiotic Therapy:

• Not applicable as this condition is not infectious.

Supportive Care:

• Pain management with analgesics.
• Monitoring for changes in symptoms.
• Counseling regarding potential surgical options.

Infection Control:

• Not applicable as this condition is not infectious.

How to Document Symptoms of Neoplasm of uncertain behavior of right ovary (ICD-10 D39.11) in SOAP Notes

Subjective:

• Patient reports intermittent right lower abdominal pain.
• Menstrual irregularities noted over the past few months.
• No significant weight loss or changes in appetite.
• Family history of ovarian cancer.

Objective:

• Abdominal examination reveals tenderness in the right lower quadrant.
• Pelvic ultrasound shows a complex cystic mass in the right ovary.
• Vital signs stable: BP 120/80, HR 72, Temp 98.6°F.
• Laboratory tests pending for tumor markers.

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SOAP Note Guidelines for Diagnosing Neoplasm of uncertain behavior of right ovary (ICD-10 Code D39.11)

Assessment:

• Diagnosis: Neoplasm of uncertain behavior of right ovary, moderate severity.
• ICD-10 Code: D39.11.
• Contributing factors: Family history of ovarian cancer.
• Further evaluation required to determine malignancy.

Plan:

• Refer for gynecological oncology consultation.
• Consider follow-up imaging in 6 weeks.
• Educate patient on signs of potential complications.
• Schedule follow-up appointment to discuss results.

Treatment & Plan Section for ICD-10 Code D39.11 – Neoplasm of uncertain behavior of right ovary

• Consideration of surgical intervention if malignancy is suspected.
• Regular monitoring with imaging studies.
• Patient education on symptom management and follow-up care.
• Referral to a specialist for further evaluation.

Using ICD-10 Code D39.11 for Neoplasm of uncertain behavior of right ovary in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use D39.11 in settings where the diagnosis is uncertain but requires monitoring.
• Align treatment plans with clinical guidelines to support billing.
• Document any relevant imaging or laboratory tests performed.

Related ICD-10 Codes Often Used with Neoplasm of uncertain behavior of right ovary

• D39.12 – Neoplasm of uncertain behavior of left ovary
• D27.9 – Benign neoplasm of unspecified ovary
• C56.9 – Malignant neoplasm of unspecified ovary

ICD-10 Code D39.11 in Medical Billing and Insurance for Neoplasm of uncertain behavior of right ovary

ICD-10 Code D39.11 is crucial for billing in hospital, ER, or outpatient settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings to support the use of D39.11.
• Use this code in conjunction with diagnostic imaging and consultations.
• Ensure compliance with payer guidelines for neoplasm coding.
• Maintain clear records of patient history and treatment plans.

Common CPT Pairings: