ICD-10 Code D48.115 | Desmoid tumor of upper extremity and shoulder girdle Symptoms, Diagnosis, Billing

Desmoid tumors, also known as aggressive fibromatosis, are benign but locally aggressive tumors that arise from connective tissue. They can occur in various locations, including the upper extremity and shoulder girdle. Accurate coding with ICD-10 Code D48.115 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 D48.115 for Desmoid tumor of upper extremity and shoulder girdle?

ICD-10 Code D48.115 specifically identifies a desmoid tumor located in the upper extremity and shoulder girdle. These tumors are characterized by their fibrous tissue composition and can cause pain or functional impairment. This code should be used in clinical documentation and billing when a patient is diagnosed with a desmoid tumor in these anatomical regions, facilitating accurate treatment and reimbursement.

ICD-10 Code D48.115 – Clinical Definition and Explanation of Desmoid tumor of upper extremity and shoulder girdle

Desmoid tumors of the upper extremity and shoulder girdle are benign neoplasms that arise from the musculoaponeurotic structures. They are often associated with trauma or surgical scars and can exhibit aggressive local behavior, necessitating medical intervention. Prompt diagnosis and management are crucial to prevent complications.

Key Clinical Features:

• Typically presents as a painless mass in the upper extremity or shoulder girdle.
• May cause local pain or discomfort due to pressure on surrounding structures.
• Can be associated with familial adenomatous polyposis (FAP) syndrome.
• Histologically characterized by spindle-shaped fibroblasts and collagen deposition.
• May require imaging studies for assessment of size and extent.

ICD-10 Code D48.115 for Desmoid tumor of upper extremity and shoulder girdle – SOAP Notes & Clinical Use

ICD-10 Code D48.115 is utilized in SOAP notes to document the presence of a desmoid tumor in the upper extremity and shoulder girdle. It plays a critical role in capturing patient symptoms, assessment findings, and treatment plans, ensuring comprehensive care in both acute and chronic settings.

What Does ICD-10 Code D48.115 for Desmoid tumor of upper extremity and shoulder girdle Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D48.115 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a desmoid tumor. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D48.115 – Desmoid tumor of upper extremity and shoulder girdle

Management of desmoid tumors may require a multidisciplinary approach, including surgical intervention and medical therapy. Hospitalization may be necessary for severe cases or complications.

Antibiotic Therapy:

Supportive Care:

• Pain management with NSAIDs or analgesics.
• Physical therapy to maintain function and mobility.
• Regular monitoring for tumor growth or recurrence.

Infection Control:

How to Document Symptoms of Desmoid tumor of upper extremity and shoulder girdle (ICD-10 D48.115) in SOAP Notes

Subjective:

• Patient reports a painless mass in the right shoulder region.
• History of previous surgery in the area with gradual mass enlargement.
• Occasional discomfort during arm movements.
• No significant weight loss or systemic symptoms reported.

Objective:

• Physical examination reveals a firm, non-tender mass measuring approximately 5 cm.
• No signs of inflammation or infection noted.
• Full range of motion in the shoulder joint despite the mass.
• Imaging shows a well-defined soft tissue mass without bony involvement.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Desmoid tumor of upper extremity and shoulder girdle (ICD-10 Code D48.115)

Assessment:

• Desmoid tumor of the upper extremity and shoulder girdle, ICD-10 Code D48.115.
• Severity classified as moderate due to size and potential for local invasion.
• No known triggers or contributing factors identified.

Plan:

• Refer to surgical oncology for evaluation of resection options.
• Consider imaging follow-up in 3-6 months to monitor tumor growth.
• Educate the patient on signs of recurrence and the importance of follow-up.
• Schedule a follow-up appointment to discuss treatment options.

Treatment & Plan Section for ICD-10 Code D48.115 – Desmoid tumor of upper extremity and shoulder girdle

• Surgical excision is the primary treatment for symptomatic desmoid tumors.
• Consideration of non-steroidal anti-inflammatory drugs (NSAIDs) for pain management.
• Regular follow-up with imaging to monitor for recurrence.
• Patient education on the nature of the tumor and potential treatment options.

Using ICD-10 Code D48.115 for Desmoid tumor of upper extremity and shoulder girdle in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
• Use the code in conjunction with relevant CPT codes for surgical procedures or imaging studies.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any complications or additional findings to support the use of this code.

Related ICD-10 Codes Often Used with Desmoid tumor of upper extremity and shoulder girdle

• D48.116 – Desmoid tumor of lower extremity and hip
• D48.117 – Desmoid tumor of trunk
• D48.118 – Desmoid tumor of other sites
• C49.9 – Malignant neoplasm of connective and soft tissue, unspecified

ICD-10 Code D48.115 in Medical Billing and Insurance for Desmoid tumor of upper extremity and shoulder girdle

ICD-10 Code D48.115 is crucial for accurate billing in hospital, ER, or outpatient settings for patients diagnosed with a desmoid tumor.

Billing Notes:

• Document the diagnosis clearly in the patient's medical record to support the claim.
• Use this code in conjunction with procedure codes for surgical interventions.
• Ensure that all relevant clinical findings are included in the documentation.
• Verify that the code is used in the appropriate clinical context to avoid claim denials.

Common CPT Pairings: