ICD-10 Code D48.110 | Desmoid tumor of head and neck Symptoms, Diagnosis, Billing

Desmoid tumors of the head and neck are rare, benign fibrous tumors that arise from connective tissue. They are characterized by aggressive local growth and can cause significant morbidity due to their location. Accurate coding with ICD-10 Code D48.110 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 D48.110 for Desmoid tumor of head and neck?

ICD-10 Code D48.110 specifically identifies desmoid tumors located in the head and neck region. These tumors are non-cancerous but can be locally aggressive, often associated with conditions like familial adenomatous polyposis. This code should be used in clinical documentation and billing when a patient presents with a confirmed diagnosis of a desmoid tumor in this anatomical area.

ICD-10 Code D48.110 – Clinical Definition and Explanation of Desmoid tumor of head and neck

Desmoid tumors of the head and neck are thought to arise from fibroblasts and are often linked to trauma or genetic predispositions. They can progress slowly but may require medical intervention due to their potential for local invasion and associated symptoms. Prompt diagnosis and treatment are crucial to prevent complications.

Key Clinical Features:

• Typically presents as a painless mass
• Can cause local symptoms due to pressure on adjacent structures
• May be associated with familial adenomatous polyposis
• Histologically characterized by infiltrative growth patterns

ICD-10 Code D48.110 for Desmoid tumor of head and neck – SOAP Notes & Clinical Use

ICD-10 Code D48.110 is utilized in SOAP notes to document the presence of a desmoid tumor in the head and neck. It aids in capturing the patient's symptoms, assessment findings, and treatment plans, ensuring comprehensive documentation in both acute and chronic care settings.

What Does ICD-10 Code D48.110 for Desmoid tumor of head and neck Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D48.110 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a desmoid tumor in the head and neck. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D48.110 – Desmoid tumor of head and neck

Desmoid tumors may require surgical intervention or other treatment modalities depending on their size and symptoms. Hospitalization may be necessary for surgical procedures or complications.

Antibiotic Therapy:

• Not applicable as desmoid tumors are not infectious

Supportive Care:

• Pain management with analgesics
• Physical therapy to maintain function
• Regular monitoring for growth or symptoms

Infection Control:

• Standard precautions during surgical interventions
• Monitoring for signs of infection post-surgery

How to Document Symptoms of Desmoid tumor of head and neck (ICD-10 D48.110) in SOAP Notes

Subjective:

• Patient reports a painless mass in the neck area
• No history of trauma noted
• Symptoms of discomfort when swallowing
• Family history of familial adenomatous polyposis

Objective:

• Physical examination reveals a firm, non-mobile mass
• No lymphadenopathy detected
• Imaging shows a well-defined soft tissue mass
• Biopsy confirms the diagnosis of a desmoid tumor

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SOAP Note Guidelines for Diagnosing Desmoid tumor of head and neck (ICD-10 Code D48.110)

Assessment:

• Diagnosis: Desmoid tumor of head and neck, benign
• ICD-10 Code: D48.110
• Severity: Moderate due to potential for local invasion
• Contributing factors: Genetic predisposition

Plan:

• Refer for surgical evaluation and possible excision
• Educate patient on monitoring for changes in mass
• Schedule follow-up in 3 months to assess for growth
• Consider genetic counseling for family members

Treatment & Plan Section for ICD-10 Code D48.110 – Desmoid tumor of head and neck

• Surgical excision is the first-line treatment
• Consideration of non-steroidal anti-inflammatory drugs (NSAIDs) for pain
• Regular imaging to monitor for recurrence
• Patient education on signs of complications

Using ICD-10 Code D48.110 for Desmoid tumor of head and neck in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and findings in SOAP notes
• Use D48.110 in conjunction with relevant CPT codes for surgical procedures
• Maintain compliance with coding guidelines to support reimbursement
• Document all patient interactions and treatment plans clearly

Related ICD-10 Codes Often Used with Desmoid tumor of head and neck

• D48.119 – Desmoid tumor, unspecified site
• C49.9 – Malignant neoplasm of connective and soft tissue, unspecified
• D37.9 – Neoplasm of uncertain behavior of unspecified site

ICD-10 Code D48.110 in Medical Billing and Insurance for Desmoid tumor of head and neck

ICD-10 Code D48.110 is crucial for billing purposes in hospital and outpatient settings, ensuring accurate coding for desmoid tumors.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis
• Use D48.110 in the appropriate clinical context to avoid claim denials
• Ensure that all treatment plans are clearly outlined in the medical record

Common CPT Pairings: