Acute lymphoblastic leukemia not having achieved remission is a hematological malignancy characterized by the proliferation of immature lymphoid cells in the bone marrow and peripheral blood. This condition is clinically significant as it indicates a failure to respond to initial treatment, necessitating further intervention. The ICD-10 Code C91.00 facilitates accurate diagnosis, documentation, and billing, ensuring appropriate care and resource allocation in public health reporting.
What is ICD-10 Code C91.00 for Acute lymphoblastic leukemia not having achieved remission?
ICD-10 Code C91.00 represents Acute lymphoblastic leukemia not having achieved remission, a subtype of leukemia where the disease persists despite treatment efforts. This code is used in clinical documentation and billing when a patient presents with ongoing symptoms or complications related to this condition, ensuring accurate representation of the patient's health status and treatment needs.
ICD-10 Code C91.00 – Clinical Definition and Explanation of Acute lymphoblastic leukemia not having achieved remission
Acute lymphoblastic leukemia not having achieved remission is caused by genetic mutations leading to the uncontrolled proliferation of lymphoblasts. The disease progresses rapidly, often resulting in severe complications such as infections, bleeding, and organ dysfunction. Immediate medical attention is crucial for managing symptoms and preventing life-threatening outcomes.
Key Clinical Features:
- Persistent fatigue and weakness due to anemia.
- Frequent infections due to neutropenia.
- Easy bruising or bleeding from thrombocytopenia.
- Lymphadenopathy and splenomegaly.
ICD-10 Code C91.00 for Acute lymphoblastic leukemia not having achieved remission – SOAP Notes & Clinical Use
ICD-10 Code C91.00 is utilized in SOAP notes to document the patient's ongoing symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation that supports clinical decision-making and billing processes.
What Does ICD-10 Code C91.00 for Acute lymphoblastic leukemia not having achieved remission Mean in SOAP Notes?
In SOAP notes, ICD-10 Code C91.00 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Acute lymphoblastic leukemia not having achieved remission. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code C91.00 – Acute lymphoblastic leukemia not having achieved remission
Management of Acute lymphoblastic leukemia not having achieved remission requires urgent intervention, often necessitating hospitalization for intensive treatment.
Antibiotic Therapy:
- Piperacillin-tazobactam (Zosyn) for broad-spectrum coverage, typically for 7-14 days.
- Cefepime as an alternative for febrile neutropenia, duration based on clinical response.
- Vancomycin for suspected MRSA infections, duration based on culture results.
Supportive Care:
- Transfusion of red blood cells and platelets to manage anemia and thrombocytopenia.
- Growth factor support (e.g., G-CSF) to stimulate neutrophil production.
- Antiemetics for nausea management during chemotherapy.
Infection Control:
- Strict hand hygiene protocols to prevent infection spread.
- Isolation precautions for neutropenic patients.
- Monitoring for signs of infection and prompt intervention.
How to Document Symptoms of Acute lymphoblastic leukemia not having achieved remission (ICD-10 C91.00) in SOAP Notes
Subjective:
- Patient reports persistent fatigue and weakness.
- History of recurrent infections over the past month.
- Complaints of easy bruising and bleeding from gums.
- Notable weight loss and decreased appetite.
Objective:
- Vital signs: BP 100/60 mmHg, HR 110 bpm, Temp 100.5°F.
- CBC shows hemoglobin 8 g/dL, platelets 50,000/mm³, WBC 2,000/mm³.
- Physical exam reveals splenomegaly and lymphadenopathy.
- Bone marrow biopsy confirms presence of lymphoblasts.
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SOAP Note Guidelines for Diagnosing Acute lymphoblastic leukemia not having achieved remission (ICD-10 Code C91.00)
Assessment:
- Diagnosis: Acute lymphoblastic leukemia not having achieved remission, severe.
- ICD-10 Code: C91.00.
- Contributing factors: Non-compliance with treatment, possible genetic predisposition.
- Severity: High risk due to persistent symptoms and laboratory findings.
Plan:
- Initiate chemotherapy regimen as per protocol.
- Administer supportive care including transfusions and antibiotics.
- Educate patient on signs of infection and importance of follow-up.
- Schedule weekly monitoring of blood counts and clinical status.
Treatment & Plan Section for ICD-10 Code C91.00 – Acute lymphoblastic leukemia not having achieved remission
- First-line pharmacologic treatments include multi-agent chemotherapy regimens.
- Non-pharmacologic strategies involve nutritional support and psychosocial counseling.
- Monitoring practices include regular CBC checks and assessment of treatment response.
- Follow-up appointments should be scheduled bi-weekly during active treatment.
Using ICD-10 Code C91.00 for Acute lymphoblastic leukemia not having achieved remission in Billing & SOAP Note Compliance
- Select accurate subcodes based on clinical severity or complications.
- Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
- Ensure treatment plans align with clinical guidelines to support justified billing.
- Only list CPT codes that are commonly billed with ICD-10 Code C91.00 based on standard medical coding practices.
Related ICD-10 Codes Often Used with Acute lymphoblastic leukemia not having achieved remission
ICD-10 Code C91.00 in Medical Billing and Insurance for Acute lymphoblastic leukemia not having achieved remission
ICD-10 Code C91.00 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.
Billing Notes:
- Ensure documentation includes detailed clinical findings and treatment plans to support the ICD-10 claim.
- Use this code in conjunction with relevant CPT codes for comprehensive billing.
- Document any complications or comorbidities that may affect treatment and billing.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 96413 | Chemotherapy administration, intravenous, push technique. |
| 36415 | Collection of venous blood by venipuncture. |
| 85027 | Complete blood count with automated differential. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code C91.00 for Acute lymphoblastic leukemia not having achieved remission
What are the common symptoms of Acute lymphoblastic leukemia not having achieved remission?
Common symptoms include persistent fatigue, frequent infections, easy bruising, and unexplained weight loss. These symptoms indicate the need for immediate medical evaluation and intervention.
How is Acute lymphoblastic leukemia not having achieved remission treated?
Treatment typically involves intensive chemotherapy, supportive care, and possibly stem cell transplantation. The approach depends on the patient's overall health and response to initial therapies.
When should ICD-10 Code C91.00 be used?
This code should be used when a patient presents with Acute lymphoblastic leukemia that has not responded to treatment, indicating ongoing disease activity and the need for further management.
What is the significance of documenting this code in EHR?
Documenting ICD-10 Code C91.00 in the EHR ensures accurate representation of the patient's condition, supports appropriate billing, and facilitates continuity of care among healthcare providers.
