Understanding Pelvic Mass: Find information on diagnosis, symptoms, and treatment options. Explore resources for healthcare professionals, including clinical documentation, medical coding (ICD-10 codes, SNOMED CT), differential diagnosis, and pelvic imaging. Learn about adnexal masses, ovarian cysts, uterine fibroids, and other related conditions. This comprehensive guide offers support for accurate and efficient pelvic mass documentation and coding for improved patient care.
Also known as
Diseases of the female genital organs
Covers various female reproductive system disorders, including masses.
Benign neoplasm of ovary
Specifically designates non-cancerous ovarian growths.
Malignant neoplasm of ovary
Identifies cancerous ovarian tumors.
Symptoms and signs involving abdomen and pelvis
Includes general abdominal and pelvic symptoms that a mass might cause.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pelvic mass specified as inflammatory?
Yes
Is the inflammatory mass further specified?
No
Is the mass neoplastic?
When to use each related code
| Description |
|---|
| Pelvic Mass |
| Ovarian Cyst |
| Uterine Fibroids |
Coding with unspecified codes (e.g., R19.0) when more specific documentation is available, impacting DRG assignment and reimbursement.
Lack of laterality (right, left, bilateral) for pelvic masses can lead to coding errors and affect accurate quality reporting and data analysis.
Coding a pelvic mass as confirmed when documented as probable, suspected, or rule-out can result in inaccurate reporting and potential compliance issues.
Q: What are the key differential diagnoses to consider when a patient presents with a complex pelvic mass and elevated CA-125, and how can I effectively differentiate between them?
A: A complex pelvic mass with elevated CA-125 often raises suspicion for ovarian cancer, but several other conditions can mimic this presentation. Differential diagnoses include benign ovarian pathologies like endometriomas, teratomas, and cystadenomas, as well as other gynecological conditions such as pelvic inflammatory disease, leiomyomas (fibroids), and ectopic pregnancy. Non-gynecological possibilities include appendiceal abscess, diverticulitis, and other pelvic malignancies. Effective differentiation relies on a combination of thorough history-taking, including menstrual history and symptom onset, physical examination, and targeted imaging. Transvaginal ultrasound is often the initial imaging modality, followed by CT or MRI if needed. Consider implementing a diagnostic algorithm that incorporates patient risk factors, such as age and family history of ovarian cancer, alongside imaging characteristics, like the presence of solid components or papillary projections within the mass, to guide management decisions. Serum markers like HE4, in conjunction with CA-125, can improve the diagnostic accuracy. Ultimately, tissue biopsy may be necessary for definitive diagnosis. Explore how our advanced imaging protocols can assist in differentiating complex pelvic masses.
Q: How can I accurately interpret pelvic MRI findings for a patient with suspected deep infiltrating endometriosis, and what are the best practices for pre-surgical planning in these complex cases?
A: Interpreting pelvic MRI for suspected deep infiltrating endometriosis requires careful evaluation for specific features. Look for the presence of ill-defined nodular lesions, often with low signal intensity on T2-weighted images, within the uterosacral ligaments, rectovaginal septum, or bowel wall. Asymmetrical thickening of the bowel wall or obliteration of the rectovaginal space are also suggestive findings. Pre-surgical planning in these complex cases is crucial for optimizing surgical outcomes. Accurate assessment of the extent of disease involvement is essential, including the location and size of endometriotic lesions, the presence of bowel or ureteral involvement, and the relationship of the disease to adjacent pelvic structures. High-quality MRI with dedicated pelvic protocols can help delineate the anatomy and guide surgical approach. Consider implementing a multidisciplinary approach, involving a gynecologic surgeon experienced in endometriosis management, a radiologist specializing in pelvic imaging, and potentially a colorectal surgeon or urologist if bowel or ureteral involvement is suspected. Learn more about our collaborative approach to complex endometriosis cases.
Patient presents with complaints concerning pelvic mass symptoms, including pelvic pain, abdominal bloating, and urinary frequency. Differential diagnosis includes ovarian cyst, uterine fibroids, pelvic inflammatory disease, endometriosis, and in rare cases, pelvic malignancies. Physical examination revealed a palpable pelvic mass with tenderness on palpation. Pelvic ultrasound was performed, demonstrating a heterogeneous mass measuring X cm x Y cm x Z cm in the (location of mass - e.g., right adnexa). The patient's CA-125 level is (result). Further imaging with CT scan or MRI of the pelvis is recommended to characterize the mass and assess for lymphadenopathy. The patient was counseled on the findings and potential need for surgical intervention, including laparoscopy or laparotomy, depending on the final diagnosis. Medical coding and billing will reflect the diagnostic procedures and consultations performed. The patient will be scheduled for follow-up in (timeframe) to discuss further management and treatment options based on imaging results. Preoperative planning and surgical clearance will be initiated if surgery is indicated. Patient education regarding pelvic mass causes, symptoms, treatment, and prognosis was provided. Documentation of informed consent for procedures and treatment plans will be obtained. The plan is to continue monitoring the patient's pelvic mass symptoms and adjust the treatment plan as needed based on ongoing clinical and radiological assessments.