ICD-10 Code D48.116 | Desmoid tumor of lower extremity and pelvic girdle Symptoms, Diagnosis, Billing

Desmoid tumors are benign fibrous neoplasms that can occur in the lower extremity and pelvic girdle. They arise from connective tissue and are characterized by local invasiveness rather than metastasis. Accurate coding with ICD-10 Code D48.116 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 D48.116 for Desmoid tumor of lower extremity and pelvic girdle?

ICD-10 Code D48.116 specifically identifies a desmoid tumor located in the lower extremity and pelvic girdle. This code is used when documenting cases of desmoid tumors, which are non-cancerous but can cause significant morbidity due to their aggressive local behavior. It is crucial for accurate clinical documentation and billing, particularly in surgical and oncological settings.

ICD-10 Code D48.116 – Clinical Definition and Explanation of Desmoid tumor of lower extremity and pelvic girdle

Desmoid tumors, also known as aggressive fibromatosis, are benign tumors that arise from the musculoaponeurotic structures. They can occur in various locations, including the lower extremity and pelvic girdle, and may cause pain or functional impairment. These tumors require careful monitoring and may necessitate surgical intervention due to their potential for local recurrence.

Key Clinical Features:

• Typically presents as a firm, palpable mass in the affected area.
• May cause pain or discomfort, particularly with movement.
• Can be associated with familial adenomatous polyposis (FAP) syndrome.
• Histologically characterized by spindle-shaped fibroblasts and collagen deposition.
• Local recurrence is common after surgical excision.

ICD-10 Code D48.116 for Desmoid tumor of lower extremity and pelvic girdle – SOAP Notes & Clinical Use

ICD-10 Code D48.116 is utilized in SOAP notes to document the presence of a desmoid tumor in the lower extremity and pelvic girdle. This code 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 D48.116 for Desmoid tumor of lower extremity and pelvic girdle Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D48.116 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of a desmoid tumor. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting electronic health record documentation standards.

Treatment Options for ICD-10 Code D48.116 – Desmoid tumor of lower extremity and pelvic girdle

Management of desmoid tumors often requires a multidisciplinary approach, including surgical and non-surgical options. While these tumors are benign, their local aggressiveness necessitates careful treatment planning.

Antibiotic Therapy:

Supportive Care:

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

Infection Control:

How to Document Symptoms of Desmoid tumor of lower extremity and pelvic girdle (ICD-10 D48.116) in SOAP Notes

Subjective:

• Patient reports a firm mass in the lower extremity.
• Experiences intermittent pain exacerbated by movement.
• No history of trauma or injury to the area.
• Family history of desmoid tumors or FAP syndrome.

Objective:

• Physical examination reveals a palpable mass in the thigh.
• No signs of erythema or warmth over the mass.
• MRI shows a well-defined soft tissue mass without bone involvement.
• Vital signs within normal limits.

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SOAP Note Guidelines for Diagnosing Desmoid tumor of lower extremity and pelvic girdle (ICD-10 Code D48.116)

Assessment:

• Diagnosis: Desmoid tumor of lower extremity and pelvic girdle, benign.
• ICD-10 Code: D48.116.
• Severity: Moderate, due to potential for local recurrence.
• Contributing factors: Family history of FAP.

Plan:

• Refer to oncology for surgical evaluation.
• Consider imaging studies for further assessment.
• Educate patient on monitoring for changes in the mass.
• Schedule follow-up in 3 months to reassess.

Treatment & Plan Section for ICD-10 Code D48.116 – Desmoid tumor of lower extremity and pelvic girdle

• Surgical excision is the primary treatment for symptomatic tumors.
• Consideration of non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief.
• Regular follow-up with imaging to monitor for recurrence.
• Referral to a specialist for potential systemic therapy if indicated.

Using ICD-10 Code D48.116 for Desmoid tumor of lower extremity and pelvic girdle 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 treatment plans that align with clinical guidelines.

Related ICD-10 Codes Often Used with Desmoid tumor of lower extremity and pelvic girdle

• D48.115 – Desmoid tumor of other sites
• C49.9 – Malignant neoplasm of connective and soft tissue, unspecified
• D18.09 – Hemangioma of other sites
• D17.9 – Benign neoplasm of unspecified connective and soft tissue

ICD-10 Code D48.116 in Medical Billing and Insurance for Desmoid tumor of lower extremity and pelvic girdle

ICD-10 Code D48.116 is crucial for accurate billing in hospital, ER, or outpatient settings, particularly for surgical interventions.

Billing Notes:

• Document all relevant clinical findings to support the use of this code.
• Use in conjunction with CPT codes for surgical procedures to ensure proper reimbursement.
• Include detailed notes on patient history and treatment plans in the medical record.
• Ensure compliance with payer-specific guidelines for coding.

Common CPT Pairings: