ICD-10 Code D3A.012 | Benign carcinoid tumor of the ileum Symptoms, Diagnosis, Billing

Benign carcinoid tumor of the ileum is a neuroendocrine tumor that arises from the enterochromaffin cells in the ileum. These tumors are typically slow-growing and may be asymptomatic for long periods. Accurate coding with ICD-10 Code D3A.012 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage this condition.

What is ICD-10 Code D3A.012 for Benign carcinoid tumor of the ileum?

ICD-10 Code D3A.012 represents a benign carcinoid tumor located in the ileum, a part of the small intestine. This code should be used when documenting cases of this specific tumor type, which may present with gastrointestinal symptoms or be discovered incidentally. Proper use of this code is crucial for accurate clinical documentation and billing processes.

ICD-10 Code D3A.012 – Clinical Definition and Explanation of Benign carcinoid tumor of the ileum

Benign carcinoid tumors of the ileum are neuroendocrine tumors that can secrete various hormones, leading to potential clinical manifestations. Although often asymptomatic, they can cause obstruction or other complications, necessitating medical evaluation and intervention.

Key Clinical Features:

• Typically slow-growing and may remain asymptomatic for years.
• Can cause abdominal pain, obstruction, or gastrointestinal bleeding.
• May secrete serotonin or other hormones, leading to carcinoid syndrome in some cases.
• More common in individuals aged 50-70 years.

ICD-10 Code D3A.012 for Benign carcinoid tumor of the ileum – SOAP Notes & Clinical Use

ICD-10 Code D3A.012 is utilized in SOAP notes to document the presence of a benign carcinoid tumor of the ileum. It aids in capturing patient symptoms, assessment findings, and treatment plans, ensuring comprehensive documentation in both acute and chronic care settings.

What Does ICD-10 Code D3A.012 for Benign carcinoid tumor of the ileum Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D3A.012 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a benign carcinoid tumor of the ileum. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D3A.012 – Benign carcinoid tumor of the ileum

Management of benign carcinoid tumors of the ileum may require hospitalization, especially if complications arise. Treatment focuses on surgical resection and symptom management.

Antibiotic Therapy:

• Not typically indicated unless there is an associated infection.
• If infection occurs, consider broad-spectrum antibiotics such as piperacillin-tazobactam.
• Duration of therapy should be guided by clinical response.

Supportive Care:

• Symptom management for abdominal pain and obstruction.
• Nutritional support if there are dietary restrictions.
• Regular monitoring for potential complications.

Infection Control:

• Standard precautions should be followed.
• Isolate patients if there is a risk of infectious complications.

How to Document Symptoms of Benign carcinoid tumor of the ileum (ICD-10 D3A.012) in SOAP Notes

Subjective:

• Patient reports intermittent abdominal pain.
• History of unexplained weight loss over the past few months.
• No significant changes in bowel habits noted.
• Occasional episodes of flushing and diarrhea.

Objective:

• Abdominal tenderness on palpation.
• No palpable masses detected during examination.
• Vital signs stable; no fever.
• Imaging shows a mass in the ileum.

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SOAP Note Guidelines for Diagnosing Benign carcinoid tumor of the ileum (ICD-10 Code D3A.012)

Assessment:

• Diagnosis: Benign carcinoid tumor of the ileum, confirmed by imaging.
• ICD-10 Code: D3A.012.
• Consideration of potential complications such as obstruction.
• No significant contributing factors identified.

Plan:

• Refer for surgical evaluation and potential resection.
• Monitor for symptoms and complications post-surgery.
• Educate the patient on dietary modifications if needed.
• Schedule follow-up appointments to assess recovery.

Treatment & Plan Section for ICD-10 Code D3A.012 – Benign carcinoid tumor of the ileum

• Surgical resection is the primary treatment for localized tumors.
• Consider somatostatin analogs for symptom control if hormonal secretion is present.
• Regular follow-up with imaging to monitor for recurrence.
• Patient education on recognizing symptoms of complications.

Using ICD-10 Code D3A.012 for Benign carcinoid tumor of the ileum in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective and Objective sections.
• Use the code in conjunction with relevant CPT codes for surgical procedures.
• Maintain compliance with coding guidelines to support reimbursement.
• Document any complications or additional procedures performed.

Related ICD-10 Codes Often Used with Benign carcinoid tumor of the ileum

• D3A.011 – Benign carcinoid tumor of the appendix
• D3A.019 – Benign carcinoid tumor of other sites

ICD-10 Code D3A.012 in Medical Billing and Insurance for Benign carcinoid tumor of the ileum

ICD-10 Code D3A.012 is critical for accurate billing in hospital, ER, or outpatient settings, particularly for surgical interventions.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use this code in conjunction with procedure codes for surgical interventions.
• Ensure that the medical necessity for procedures is clearly documented.
• Review payer-specific guidelines for coding and billing.

Common CPT Pairings: