ICD-10 Code D48.114 | Desmoid tumor, intraabdominal Symptoms, Diagnosis, Billing

Desmoid tumors, also known as aggressive fibromatosis, are benign but locally aggressive tumors that arise from connective tissue. Intraabdominal desmoid tumors can occur in various locations within the abdominal cavity and may be associated with familial adenomatous polyposis (FAP). Accurate coding with ICD-10 Code D48.114 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 D48.114 for Desmoid tumor, intraabdominal?

ICD-10 Code D48.114 specifically identifies desmoid tumors located in the intraabdominal region. These tumors are characterized by their fibrous tissue composition and can cause significant morbidity due to their aggressive local behavior. This code should be used in clinical documentation and billing when a patient is diagnosed with an intraabdominal desmoid tumor, ensuring accurate representation of the patient's condition for treatment and reimbursement purposes.

ICD-10 Code D48.114 – Clinical Definition and Explanation of Desmoid tumor, intraabdominal

Desmoid tumors, particularly those found intraabdominally, are non-metastatic tumors that arise from the musculoaponeurotic structures. They can be sporadic or associated with genetic syndromes such as familial adenomatous polyposis. Due to their potential for local invasion and recurrence, they require careful monitoring and management.

Key Clinical Features:

• Typically presents as a palpable mass or abdominal pain.
• May be associated with familial adenomatous polyposis (FAP).
• Can cause bowel obstruction or other complications due to local growth.
• Histologically characterized by spindle-shaped fibroblasts.

ICD-10 Code D48.114 for Desmoid tumor, intraabdominal – SOAP Notes & Clinical Use

ICD-10 Code D48.114 is utilized in SOAP notes to document the presence of an intraabdominal desmoid tumor. It plays a crucial role in capturing the patient's symptoms, assessment findings, and treatment plans, facilitating effective communication among healthcare providers in both acute and chronic care settings.

What Does ICD-10 Code D48.114 for Desmoid tumor, intraabdominal Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D48.114 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of an intraabdominal desmoid tumor. This code ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D48.114 – Desmoid tumor, intraabdominal

Management of intraabdominal desmoid tumors often requires a multidisciplinary approach, including surgical intervention and monitoring. Due to the potential for local recurrence, timely treatment is essential.

Antibiotic Therapy:

• Not applicable as desmoid tumors are not infectious.

Supportive Care:

• Pain management with analgesics.
• Nutritional support if bowel obstruction occurs.
• Regular imaging to monitor tumor growth.

Infection Control:

• Standard precautions during surgical interventions.

How to Document Symptoms of Desmoid tumor, intraabdominal (ICD-10 D48.114) in SOAP Notes

Subjective:

• Patient reports abdominal pain and discomfort.
• History of familial adenomatous polyposis (FAP).
• Notable increase in abdominal girth over the past month.
• Reports changes in bowel habits.

Objective:

• Palpable mass in the right lower quadrant.
• Abdominal tenderness on examination.
• Imaging shows a well-defined mass in the intraabdominal cavity.
• No signs of acute obstruction on imaging.

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SOAP Note Guidelines for Diagnosing Desmoid tumor, intraabdominal (ICD-10 Code D48.114)

Assessment:

• Diagnosis: Intraabdominal desmoid tumor (ICD-10 D48.114).
• Severity: Moderate, with potential for local invasion.
• Contributing factors: History of familial adenomatous polyposis.
• Monitoring for complications such as bowel obstruction.

Plan:

• Refer to surgical oncology for evaluation of resection.
• Consider imaging follow-up in 3-6 months.
• Educate patient on signs of complications.
• Schedule follow-up appointment to discuss treatment options.

Treatment & Plan Section for ICD-10 Code D48.114 – Desmoid tumor, intraabdominal

• Surgical resection is the primary treatment for symptomatic tumors.
• Consideration of non-surgical options such as observation or medication for asymptomatic cases.
• Regular follow-up with imaging to monitor for recurrence.
• Patient education on recognizing symptoms of complications.

Using ICD-10 Code D48.114 for Desmoid tumor, intraabdominal in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings under Subjective (S) and Objective (O).
• Use the code in conjunction with relevant CPT codes for surgical procedures or imaging.
• Document treatment plans that align with clinical guidelines to support justified billing.
• Review coding updates regularly to ensure compliance with payer requirements.

Related ICD-10 Codes Often Used with Desmoid tumor, intraabdominal

• D48.115 – Desmoid tumor, extraabdominal
• C49.9 – Malignant neoplasm of connective and soft tissue, unspecified

ICD-10 Code D48.114 in Medical Billing and Insurance for Desmoid tumor, intraabdominal

ICD-10 Code D48.114 is critical in medical billing, particularly in hospital and surgical settings, to ensure accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the use of this code.
• Use in conjunction with appropriate CPT codes for surgical interventions.
• Ensure that the diagnosis is clearly linked to the patient's symptoms and treatment in the medical record.
• Review payer-specific guidelines for any additional documentation requirements.

Common CPT Pairings: