Find comprehensive information on neck mass diagnosis, including differential diagnosis, clinical evaluation, imaging studies (ultrasound, CT, MRI), fine needle aspiration biopsy, lymph node examination, and relevant ICD-10 codes. Learn about common causes such as lymphadenopathy, thyroid nodules, branchial cleft cysts, and cancerous tumors. This resource provides valuable insights for healthcare professionals, focusing on accurate documentation and medical coding for neck masses. Explore best practices for managing and treating neck masses, including surgical approaches and medical management.
Also known as
Localized swelling, mass and lump
Abnormal swellings, lumps, or masses in specific body areas, including the neck.
Secondary malignant neoplasm of lymph nodes
Cancer spread to lymph nodes, potentially presenting as neck masses.
Benign neoplasm of lip, oral cavity and pharynx
Non-cancerous growths in the mouth and throat area, which can sometimes cause neck masses.
Malignant neoplasm of thyroid gland
Thyroid cancer, often presenting as a lump or mass in the neck.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the neck mass inflammatory?
Yes
Acute lymphadenitis?
No
Is it a cyst?
When to use each related code
| Description |
|---|
| Neck Mass |
| Lymphadenopathy |
| Thyroid Nodule |
Coding neck mass without specifying laterality (right, left, or bilateral) can lead to claim rejections and inaccurate data reporting. Impacts reimbursement and quality metrics.
Failing to document the underlying cause of the neck mass (e.g., infection, congenital) hinders accurate coding and CDI efforts. Affects clinical documentation improvement programs.
Inadequate documentation of the neck mass size impacts coding specificity and may trigger audits. Relevant for medical coding compliance and accurate staging.
Patient presents with a neck mass (cervical lymphadenopathy, neck lump, swollen gland). Chief complaint includes [patient's primary concern regarding the mass; e.g., palpable lump, pain, difficulty swallowing, cosmetic concern]. Onset of the mass was [timeframe; e.g., gradual over several months, sudden onset last week]. Associated symptoms include [list associated symptoms; e.g., fever, night sweats, weight loss, dysphagia, odynophagia, hoarseness, ear pain, upper respiratory infection symptoms]. Location of the mass is [describe location; e.g., anterior cervical triangle, posterior cervical triangle, supraclavicular, submandibular, midline]. The mass is characterized as [describe characteristics; e.g., mobile, fixed, firm, soft, tender, non-tender, size in centimeters]. Past medical history includes [relevant medical history; e.g., history of cancer, thyroid disease, infectious mononucleosis, recent infection]. Social history includes [relevant social history; e.g., tobacco use, alcohol use, occupational exposures]. Medications include [list current medications]. Allergies include [list allergies]. Physical examination reveals [describe findings; e.g., palpable lymph nodes, skin changes, respiratory distress, neurological deficits]. Differential diagnosis includes [list possible diagnoses; e.g., lymphadenitis, lymphoma, metastatic cancer, benign tumor, branchial cleft cyst, thyroglossal duct cyst]. Plan includes [outline plan; e.g., complete blood count with differential, comprehensive metabolic panel, thyroid function tests, ultrasound of the neck, fine needle aspiration biopsy, referral to ENT, oncology consult, close monitoring]. ICD-10 code considerations include [list relevant ICD-10 codes; e.g., R22.2, D47.0, C77.0]. Patient education provided regarding possible causes, diagnostic testing, and follow-up care. Return to clinic scheduled for [date].