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v1.0.0
ICD-10 Guide
ICD-10 CodesC49.0

C49.0

Billable

Malignant neoplasm of connective and soft tissue of head, face and neck

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 C49.0 is a billable code used to indicate a diagnosis of malignant neoplasm of connective and soft tissue of head, face and neck.

Key Diagnostic Point:

C49.0 refers to malignant neoplasms originating in the connective and soft tissues located in the head, face, and neck regions. These tumors can arise from various types of soft tissue, including adipose tissue, fibrous tissue, and vascular tissue. Soft tissue sarcomas in these areas are relatively rare but can be aggressive and may present with symptoms such as swelling, pain, or changes in the appearance of the affected area. Diagnosis typically involves imaging studies, such as MRI or CT scans, and a biopsy to confirm malignancy. Grading of these tumors is crucial, as it helps determine the prognosis and treatment options. Multidisciplinary management is essential, often involving surgical resection, radiation therapy, and chemotherapy, depending on the tumor's size, location, and histological type. Close follow-up is necessary due to the potential for local recurrence and metastasis.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variability in tumor histology and grading
  • Need for precise documentation of tumor location and size
  • Multidisciplinary treatment approaches
  • Potential for local recurrence and metastasis

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to capture the multidisciplinary approach to treatment
  • Misclassification of tumor grade
  • Omission of follow-up care details

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with soft tissue masses, requiring biopsy and staging.

Billing Considerations

Ensure accurate coding of tumor grade and staging to reflect treatment decisions.

Surgery

Documentation Requirements

Operative reports detailing the extent of resection and margins.

Common Clinical Scenarios

Surgical intervention for soft tissue sarcomas, including limb-sparing procedures.

Billing Considerations

Document the surgical approach and any complications that may affect coding.

Coding Guidelines

Inclusion Criteria

Use C49.0 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the tumor's location, size, and histological type
  • Include any relevant staging information and treatment plans

Exclusion Criteria

Do NOT use C49.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

38500CPT Code

Biopsy of soft tissue

Clinical Scenario

Used when a biopsy is performed to confirm the diagnosis of a soft tissue sarcoma.

Documentation Requirements

Document the site of the biopsy and the method used.

Specialty Considerations

Oncology specialists should ensure that the biopsy results are linked to the diagnosis.

19301CPT Code

Mastectomy, partial

Clinical Scenario

When a patient with a soft tissue sarcoma in the breast undergoes surgical intervention.

Documentation Requirements

Document the extent of the surgery and any findings.

Specialty Considerations

Surgical oncologists must provide detailed operative notes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of soft tissue sarcomas, improving the accuracy of data collection and reimbursement processes. C49.0 provides granularity that aids in research and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of soft tissue sarcomas, improving the accuracy of data collection and reimbursement processes. C49.0 provides granularity that aids in research and treatment planning.

Reimbursement & Billing Impact

reimbursement processes. C49.0 provides granularity that aids in research and treatment planning.

Resources

Clinical References

  • •
    American Cancer Society - Soft Tissue Sarcoma

Coding & Billing References

  • •
    American Cancer Society - Soft Tissue Sarcoma

Frequently Asked Questions

What is the significance of tumor grading in C49.0?

Tumor grading is crucial as it helps determine the aggressiveness of the cancer and guides treatment decisions. High-grade tumors typically require more aggressive treatment compared to low-grade tumors.