Find information on esophageal mass diagnosis, including clinical documentation, medical coding, and healthcare guidance. Learn about symptoms, diagnostic procedures like endoscopy and biopsy, and ICD-10 codes related to esophageal masses, tumors, and neoplasms. Explore resources for healthcare professionals on proper documentation and coding for esophageal cancer, benign esophageal tumors, and other related conditions. This resource helps with accurate clinical documentation and appropriate medical coding for esophageal masses.
Also known as
Esophageal disorders
Covers specific esophageal conditions, including masses/tumors.
Benign neoplasm of esophagus
Identifies non-cancerous esophageal growths.
Malignant neoplasm of esophagus
Classifies cancerous tumors within the esophagus.
Symptoms/signs involving digestive system
May be used if specific diagnosis is uncertain/unavailable initially.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the esophageal mass malignant?
Yes
Specify morphology
No
Is it benign?
When to use each related code
Description |
---|
Mass in esophagus |
Esophageal cancer |
Esophageal leiomyoma |
Patient presents with complaints suggestive of esophageal mass, including dysphagia, odynophagia, and retrosternal chest pain. Symptoms onset and duration were documented. Review of systems includes weight loss, regurgitation, cough, and hoarseness. Past medical history, family history, and social history including tobacco and alcohol use were reviewed. Physical examination findings were noted, including vital signs and any relevant lymphadenopathy. Differential diagnosis includes esophageal cancer, benign esophageal tumor, esophageal stricture, and achalasia. Preliminary diagnostic impression is esophageal mass, likely neoplastic versus non-neoplastic. Ordered esophagogastroduodenoscopy (EGD) with biopsy for histopathological evaluation to confirm diagnosis and determine malignancy. Patient education provided regarding the procedure, potential complications, and the importance of follow-up. Further management will be determined based on biopsy results and may include endoscopic ultrasound, computed tomography (CT) scan of the chest and abdomen, barium swallow study, and consultation with oncology, gastroenterology, and thoracic surgery as indicated. ICD-10 code for esophageal mass to be determined based on biopsy results. CPT codes for EGD with biopsy will be documented upon procedure completion. Patient advised to return to clinic for follow-up and discussion of results. Treatment plan will be developed based on final diagnosis and staging. Potential treatment options include surgical resection, chemotherapy, radiation therapy, endoscopic therapies, and palliative care, dependent upon patient needs and preferences.