Acute lymphoblastic leukemia (ALL) is a type of cancer that affects the blood and bone marrow, characterized by the overproduction of immature lymphocytes. When classified as 'in remission,' it indicates that the disease is not currently active, which is crucial for treatment planning and monitoring. The ICD-10 Code C91.01 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track patient outcomes and resource utilization.
What is ICD-10 Code C91.01 for Acute lymphoblastic leukemia, in remission?
ICD-10 Code C91.01 represents Acute lymphoblastic leukemia, in remission. This code is used when a patient has achieved remission from ALL, indicating that the signs and symptoms of the disease are no longer present. It is essential for clinical documentation and billing to reflect the patient's current status accurately, ensuring appropriate treatment plans and resource allocation.
ICD-10 Code C91.01 – Clinical Definition and Explanation of Acute lymphoblastic leukemia, in remission
Acute lymphoblastic leukemia, in remission, occurs when the aggressive proliferation of lymphoblasts has been controlled, leading to a significant reduction in disease symptoms. This condition requires ongoing medical supervision to monitor for potential relapse and manage any residual effects of treatment.
Key Clinical Features:
- Presence of immature lymphocytes in the blood and bone marrow.
- Symptoms may include fatigue, fever, and easy bruising.
- Requires regular monitoring for relapse and treatment side effects.
- Typically diagnosed in children but can occur in adults.
ICD-10 Code C91.01 for Acute lymphoblastic leukemia, in remission – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code C91.01 is utilized to document the patient's remission status, guiding clinical assessments and treatment plans. It plays a vital role in both acute and chronic care settings, ensuring that healthcare providers have a clear understanding of the patient's current health status.
What Does ICD-10 Code C91.01 for Acute lymphoblastic leukemia, in remission Mean in SOAP Notes?
ICD-10 Code C91.01 connects subjective reports of symptoms and objective clinical findings to a formal diagnosis of remission in acute lymphoblastic leukemia. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code C91.01 – Acute lymphoblastic leukemia, in remission
Management of Acute lymphoblastic leukemia, in remission, focuses on maintaining remission and preventing relapse. Treatment strategies may include ongoing chemotherapy and supportive care.
Antibiotic Therapy:
- Not typically indicated unless there is an infection; consider prophylactic antibiotics in high-risk patients.
- First-line: Amoxicillin or Cephalexin for bacterial infections.
- Alternative: Clindamycin for penicillin-allergic patients.
- Duration: Typically 7-14 days, depending on the infection.
Supportive Care:
- Regular follow-up appointments for monitoring.
- Management of side effects from previous treatments.
- Nutritional support to maintain health.
- Psychosocial support for emotional well-being.
Infection Control:
- Strict hand hygiene practices.
- Avoiding exposure to sick individuals.
- Vaccination updates as per healthcare provider recommendations.
- Monitoring for signs of infection, especially during treatment.
How to Document Symptoms of Acute lymphoblastic leukemia, in remission (ICD-10 C91.01) in SOAP Notes
Subjective:
- Patient reports feeling well with no current symptoms.
- Denies fatigue, fever, or unusual bruising.
- History of previous treatment for ALL, currently in remission.
- Expresses concerns about potential relapse.
Objective:
- Vital signs stable: BP 120/80, HR 72, Temp 98.6°F.
- Physical examination shows no lymphadenopathy or hepatosplenomegaly.
- Blood tests indicate normal complete blood count (CBC).
- Bone marrow biopsy shows no evidence of leukemic cells.
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SOAP Note Guidelines for Diagnosing Acute lymphoblastic leukemia, in remission (ICD-10 Code C91.01)
Assessment:
- Diagnosis: Acute lymphoblastic leukemia, in remission.
- ICD-10 Code: C91.01.
- No current symptoms or signs of relapse.
- Patient education on signs of potential relapse provided.
Plan:
- Continue regular follow-up every 3 months.
- Monitor blood counts and overall health.
- Educate patient on lifestyle modifications to support health.
- Schedule next appointment in 3 months.
Treatment & Plan Section for ICD-10 Code C91.01 – Acute lymphoblastic leukemia, in remission
- Regular follow-up appointments to monitor remission status.
- Consider ongoing low-dose chemotherapy if indicated.
- Patient education on recognizing signs of relapse.
- Psychosocial support services referral as needed.
Using ICD-10 Code C91.01 for Acute lymphoblastic leukemia, in remission in Billing & SOAP Note Compliance
- Ensure accurate documentation of remission status in patient records.
- Use C91.01 in conjunction with relevant treatment codes for billing.
- Document any complications or additional treatments to support claims.
- Maintain compliance with coding guidelines to avoid denials.
Related ICD-10 Codes Often Used with Acute lymphoblastic leukemia, in remission
- C91.00 – Acute lymphoblastic leukemia, not having achieved remission
- C91.02 – Acute lymphoblastic leukemia, in relapse
ICD-10 Code C91.01 in Medical Billing and Insurance for Acute lymphoblastic leukemia, in remission
ICD-10 Code C91.01 is essential for accurate billing in hospital, ER, or infectious disease care settings, reflecting the patient's remission status.
Billing Notes:
- Document all relevant clinical findings and treatment plans to support the claim.
- Use C91.01 in conjunction with procedure codes for comprehensive billing.
- Ensure that all documentation aligns with coding guidelines to prevent denials.
- Review patient history for any complications that may affect billing.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, moderate complexity. |
| 36415 | Collection of venous blood by venipuncture. |
| 85025 | Complete blood count (CBC) with automated differential. |
| 85027 | Complete blood count (CBC) with manual differential. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code C91.01 for Acute lymphoblastic leukemia, in remission
What does it mean for Acute lymphoblastic leukemia to be in remission?
Remission in Acute lymphoblastic leukemia indicates that the signs and symptoms of the disease are no longer present, and the patient is responding well to treatment. Regular monitoring is essential to ensure that the disease does not return.
How is remission determined in patients with Acute lymphoblastic leukemia?
Remission is typically determined through clinical evaluations, blood tests, and bone marrow biopsies that show no evidence of leukemic cells. Ongoing assessments are crucial to monitor for any signs of relapse.
What are the common treatments for maintaining remission in Acute lymphoblastic leukemia?
Common treatments include ongoing chemotherapy, regular follow-up appointments, and supportive care to manage any side effects. Patients may also receive psychosocial support to address emotional well-being.
How does ICD-10 Code C91.01 affect billing and insurance claims?
ICD-10 Code C91.01 is critical for accurate billing and insurance claims, as it reflects the patient's remission status. Proper documentation ensures that healthcare providers receive appropriate reimbursement for services rendered.
