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D49.0
ICD-10-CM
Mass in Esophagus

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 Tumor
Esophageal Neoplasm

Diagnosis Snapshot

Key Facts
  • Definition : Abnormal tissue growth inside the esophagus.
  • Clinical Signs : Difficulty swallowing, chest pain, heartburn, weight loss, vomiting.
  • Common Settings : Outpatient clinic, endoscopy suite, hospital.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC D49.0 Coding
K22.0-K22.9

Esophageal disorders

Covers specific esophageal conditions, including masses/tumors.

D13.1

Benign neoplasm of esophagus

Identifies non-cancerous esophageal growths.

C15.0-C15.9

Malignant neoplasm of esophagus

Classifies cancerous tumors within the esophagus.

R18

Symptoms/signs involving digestive system

May be used if specific diagnosis is uncertain/unavailable initially.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Mass in esophagus
Esophageal cancer
Esophageal leiomyoma

Documentation Best Practices

Documentation Checklist
  • Esophageal mass size, location, characteristics documented.
  • Symptoms: dysphagia, odynophagia, etc. specified.
  • Diagnostic methods: EGD, biopsy, imaging results included.
  • Histopathology if biopsy performed, TNM staging if applicable.
  • Differential diagnosis considered and documented.

Mitigation Tips

Best Practices
  • Code accurately: Use ICD-10-CM codes for esophageal masses, like C15.X for malignant, D13.1 for benign.
  • Document precisely: Include mass size, location, type, and symptoms for optimal CDI and coding.
  • Review pathology reports: Verify diagnosis, confirm histology for accurate coding and staging.
  • Multidisciplinary approach: GI, radiology, pathology input ensures thorough diagnosis and treatment plan.
  • Timely follow-up: Document post-procedure findings, treatment response, and complications for compliance.

Clinical Decision Support

Checklist
  • Verify dysphagia, odynophagia, or retrosternal pain documented (ICD-10 R13.1)
  • Confirm imaging (e.g., barium swallow, EGD) shows esophageal mass (SNOMED CT 387709009)
  • Check biopsy pathology report for malignancy vs. benign nature (ICD-O-3)
  • Evaluate for weight loss, anemia, or other systemic symptoms (patient safety)
  • Review swallowing study if aspiration risk present (SNOMED CT 408965000)

Reimbursement and Quality Metrics

Impact Summary
  • Esophagus Mass Reimbursement: Coding accuracy impacts CMI, RVUs, denials.
  • Quality Metrics: Accurate diagnosis coding affects quality reporting, hospital rankings.
  • Coding for Esophagus Mass: ICD-10 specificity (e.g., C15.0-C15.9) crucial for proper reimbursement.
  • Denial Prevention: Precise EGD procedure coding (e.g., 43200-43259) linked to mass diagnosis maximizes payment.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code location, size, morphology
  • Rule out esophageal duplication cyst
  • Consider benign vs malignant, stage if applicable
  • Document dysphagia, odynophagia details
  • Check documentation for biopsy, imaging results

Documentation Templates

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.