ICD-10 Code C91.02 | Acute lymphoblastic leukemia, in relapse Symptoms, Diagnosis, Billing

Acute lymphoblastic leukemia, in relapse is a hematological malignancy characterized by the proliferation of immature lymphoid cells. This condition signifies a return of the disease after a period of remission, necessitating precise documentation and coding for effective treatment planning, billing, and public health reporting. The ICD-10 Code C91.02 facilitates accurate diagnosis and ensures compliance with healthcare regulations.

What is ICD-10 Code C91.02 for Acute lymphoblastic leukemia, in relapse?

ICD-10 Code C91.02 represents Acute lymphoblastic leukemia, in relapse, indicating a recurrence of this aggressive cancer of the blood and bone marrow. This code is utilized when documenting a patient's return to a state of active disease following remission, ensuring appropriate treatment protocols and billing practices are followed.

ICD-10 Code C91.02 – Clinical Definition and Explanation of Acute lymphoblastic leukemia, in relapse

Acute lymphoblastic leukemia, in relapse occurs when previously treated patients experience a resurgence of lymphoblasts in the bone marrow and peripheral blood. This condition requires immediate medical intervention due to its rapid progression and potential complications.

Key Clinical Features:

• Reappearance of symptoms such as fatigue, fever, and bleeding.
• Increased lymphoblasts in peripheral blood and bone marrow.
• Potential for severe complications including infections and organ dysfunction.
• Higher incidence in children, but can occur in adults.

ICD-10 Code C91.02 for Acute lymphoblastic leukemia, in relapse – SOAP Notes & Clinical Use

ICD-10 Code C91.02 is integral in SOAP notes for documenting the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive care and accurate billing.

What Does ICD-10 Code C91.02 for Acute lymphoblastic leukemia, in relapse Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C91.02 connects subjective patient reports and objective clinical findings to a formal diagnosis of relapse. This code supports continuity of care, facilitates accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code C91.02 – Acute lymphoblastic leukemia, in relapse

Acute lymphoblastic leukemia, in relapse requires urgent medical intervention, often necessitating hospitalization for intensive treatment.

Antibiotic Therapy:

• Cefepime: First-line, typically for 7-14 days.
• Piperacillin-tazobactam: Alternative, duration based on clinical response.
• Meropenem: Considered for resistant infections, duration as needed.

Supportive Care:

• Blood transfusions to manage anemia and thrombocytopenia.
• Antiemetics for nausea management.
• Hydration and electrolyte management to prevent complications.

Infection Control:

• Strict hand hygiene protocols.
• Isolation precautions for neutropenic patients.
• Monitoring for signs of infection during treatment.

How to Document Symptoms of Acute lymphoblastic leukemia, in relapse (ICD-10 C91.02) in SOAP Notes

Subjective:

• Patient reports increased fatigue and recurrent fevers.
• History of easy bruising and bleeding gums.
• Complaints of bone pain and night sweats.

Objective:

• Vital signs: Elevated temperature of 101°F.
• CBC shows leukocytosis with increased lymphoblasts.
• Physical exam reveals splenomegaly and pallor.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Acute lymphoblastic leukemia, in relapse (ICD-10 Code C91.02)

Assessment:

• Diagnosis: Acute lymphoblastic leukemia, in relapse (ICD-10 C91.02).
• Severity: High due to symptomatic presentation.
• Triggers: Previous treatment history and potential exposure to infections.

Plan:

• Initiate chemotherapy regimen as per protocol.
• Administer supportive care including transfusions.
• Schedule follow-up CBC in 1 week to monitor response.
• Educate patient on signs of infection and when to seek care.

Treatment & Plan Section for ICD-10 Code C91.02 – Acute lymphoblastic leukemia, in relapse

• First-line pharmacologic treatments include chemotherapy agents such as vincristine and prednisone.
• Non-pharmacologic strategies involve nutritional support and psychosocial counseling.
• Monitoring practices include regular CBC checks and assessment of organ function.
• Follow-up appointments should be scheduled bi-weekly during treatment.

Using ICD-10 Code C91.02 for Acute lymphoblastic leukemia, in relapse 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.
• Commonly billed CPT codes include 96413 for chemotherapy administration.

Related ICD-10 Codes Often Used with Acute lymphoblastic leukemia, in relapse

• C91.00 – Acute lymphoblastic leukemia, not having achieved remission
• C91.01 – Acute lymphoblastic leukemia, in remission

ICD-10 Code C91.02 in Medical Billing and Insurance for Acute lymphoblastic leukemia, in relapse

ICD-10 Code C91.02 is crucial for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure documentation includes detailed patient history and treatment plans.
• Use this code in conjunction with relevant CPT codes for chemotherapy administration.
• Document all clinical findings to support the medical necessity of the treatment.

Common CPT Pairings: