Understanding Left Adnexal Mass diagnosis, symptoms, and treatment options. Find information on ICD-10 codes, SNOMED CT codes, medical billing, and clinical documentation best practices for Left Adnexal Mass. Explore differential diagnoses, ultrasound findings, and ovarian cyst vs. other adnexal pathologies. Learn about pelvic pain, adnexal tenderness, and other relevant clinical findings associated with a Left Adnexal Mass. This resource provides valuable insights for healthcare professionals, medical coders, and patients seeking information on Left Adnexal Mass.
Also known as
Diseases of breast
Includes inflammatory conditions, cysts, and masses of the breast.
Inflammatory diseases of female pelvic organs
Covers inflammatory conditions of the ovaries, fallopian tubes, and other pelvic structures.
Benign neoplasm of ovary
Specifically designates benign growths and tumors of the ovary.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the left adnexal mass physiological (e.g., corpus luteum cyst)?
Yes
Code as appropriate physiological condition (e.g., N83.0 for corpus luteum cyst).
No
Is the mass inflammatory (e.g., tubo-ovarian abscess)?
When to use each related code
| Description |
|---|
| Left adnexal mass |
| Ovarian cyst, left |
| Left fallopian tube mass |
Coding left adnexal mass without specifying laterality can lead to inaccurate data and rejected claims. Use specific ICD-10 codes.
Insufficient documentation of the mass characteristics (size, type, symptoms) hinders accurate code assignment and may trigger audits.
Coding a left adnexal mass as confirmed without definitive diagnostic evidence (e.g., imaging, pathology) increases compliance risks.
Patient presents with complaints concerning for a left adnexal mass. Presenting symptoms include (but are not limited to) pelvic pain, abdominal pain, bloating, abdominal distension, and abnormal vaginal bleeding. Patient may also report pressure, fullness, or a palpable mass. Physical examination findings may reveal tenderness to palpation in the left lower quadrant, a palpable adnexal mass on bimanual exam, or cervical motion tenderness. Differential diagnosis includes ovarian cyst, ovarian tumor, ectopic pregnancy, hydrosalpinx, pelvic inflammatory disease, and endometriosis. Ultrasound imaging of the pelvis is indicated to evaluate the size, shape, and characteristics of the adnexal mass, assessing for features suggestive of malignancy such as solid components, irregular borders, or ascites. CA-125 levels may be obtained, though their utility in premenopausal women is limited. Treatment plan is dependent upon the characteristics of the mass and may include watchful waiting with repeat ultrasound imaging, medical management with hormonal therapy, or surgical intervention such as laparoscopy or laparotomy for removal of the mass. Patient education regarding the potential risks and benefits of each treatment option was provided. The patient was counseled on the importance of follow-up care and scheduled for a return visit to discuss further management. ICD-10 code N83.20, unspecified ovarian cyst, may be considered depending on ultrasound findings. CPT codes for procedures performed, such as pelvic ultrasound (76830) or laparoscopy (e.g., 58662), should be documented accordingly. Further evaluation and management will be determined based on imaging results and patient response to initial management.