ICD-10 Code C91.40 | Hairy cell leukemia not having achieved remission Symptoms, Diagnosis, Billing

Hairy cell leukemia not having achieved remission is a rare type of chronic leukemia characterized by the proliferation of abnormal B lymphocytes with hairy projections. This condition is clinically significant as it can lead to severe complications, including splenomegaly, cytopenias, and increased susceptibility to infections. Accurate coding with ICD-10 Code C91.40 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and resources.

What is ICD-10 Code C91.40 for Hairy cell leukemia not having achieved remission?

ICD-10 Code C91.40 represents Hairy cell leukemia not having achieved remission, indicating that the disease has not responded to treatment. This code is used when documenting cases where the leukemia persists despite therapeutic interventions, highlighting the need for ongoing management and monitoring. It is crucial for accurate clinical documentation and billing, ensuring that healthcare providers can track treatment efficacy and patient outcomes.

ICD-10 Code C91.40 – Clinical Definition and Explanation of Hairy cell leukemia not having achieved remission

Hairy cell leukemia not having achieved remission is a hematological malignancy that arises from the clonal proliferation of atypical B lymphocytes. The condition is characterized by its resistance to standard treatments, necessitating specialized management. Patients require close monitoring due to the risk of severe complications and the potential for disease progression.

Key Clinical Features:

• Presence of hairy cells in peripheral blood and bone marrow.
• Splenomegaly and lymphadenopathy.
• Cytopenias, including anemia and thrombocytopenia.
• Increased risk of infections due to immunosuppression.

ICD-10 Code C91.40 for Hairy cell leukemia not having achieved remission – SOAP Notes & Clinical Use

ICD-10 Code C91.40 is utilized in SOAP notes to document the ongoing nature of Hairy cell leukemia that has not achieved remission. This code aids in capturing the patient's symptoms, assessment findings, and treatment plans, ensuring comprehensive documentation in both acute and chronic care settings.

What Does ICD-10 Code C91.40 for Hairy cell leukemia not having achieved remission Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C91.40 connects subjective patient reports and objective clinical findings to a formal diagnosis of Hairy cell leukemia not having achieved remission. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting electronic health record documentation standards.

Treatment Options for ICD-10 Code C91.40 – Hairy cell leukemia not having achieved remission

Management of Hairy cell leukemia not having achieved remission requires a multidisciplinary approach, often necessitating hospitalization for intensive treatment. Therapeutic strategies focus on controlling symptoms and preventing complications.

Antibiotic Therapy:

• First-line: Cladribine (typically administered over 7 days).
• Alternative: Pentostatin (administered every 2 weeks).
• Supportive antibiotics for infections as needed.

Supportive Care:

• Transfusions for anemia and thrombocytopenia.
• Growth factors to stimulate blood cell production.
• Monitoring for infections and providing prophylactic antibiotics.

Infection Control:

• Strict hand hygiene and isolation precautions during outbreaks.
• Vaccination against preventable infections.
• Education on recognizing signs of infection early.

How to Document Symptoms of Hairy cell leukemia not having achieved remission (ICD-10 C91.40) in SOAP Notes

Subjective:

• Patient reports fatigue and weakness.
• History of recurrent infections over the past month.
• Complaints of abdominal discomfort due to splenomegaly.
• Patient expresses concern about bruising and bleeding.

Objective:

• Physical examination reveals splenomegaly.
• Complete blood count shows anemia and thrombocytopenia.
• Bone marrow biopsy confirms the presence of hairy cells.
• Vital signs stable, but patient appears pale.

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SOAP Note Guidelines for Diagnosing Hairy cell leukemia not having achieved remission (ICD-10 Code C91.40)

Assessment:

• Diagnosis: Hairy cell leukemia not having achieved remission, severe.
• ICD-10 Code: C91.40.
• Contributing factors: Previous treatment failure and ongoing cytopenias.
• Patient's condition requires close monitoring and potential hospitalization.

Plan:

• Initiate treatment with Cladribine as per protocol.
• Provide supportive care including blood transfusions as needed.
• Educate patient on signs of infection and when to seek care.
• Schedule follow-up in 2 weeks to assess treatment response.

Treatment & Plan Section for ICD-10 Code C91.40 – Hairy cell leukemia not having achieved remission

• First-line treatment with Cladribine or Pentostatin.
• Regular monitoring of blood counts and symptoms.
• Patient education on infection prevention and management.
• Follow-up appointments to assess treatment efficacy and adjust care.

Using ICD-10 Code C91.40 for Hairy cell leukemia not having achieved remission in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and treatment plans.
• Use C91.40 in settings where ongoing management is required.
• Document all relevant clinical findings to support billing.
• Align treatment plans with clinical guidelines for justified billing.

Related ICD-10 Codes Often Used with Hairy cell leukemia not having achieved remission

• C91.41 – Hairy cell leukemia in remission
• C91.42 – Hairy cell leukemia, recurrent

ICD-10 Code C91.40 in Medical Billing and Insurance for Hairy cell leukemia not having achieved remission

ICD-10 Code C91.40 is critical in medical billing, particularly in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all patient interactions and treatment details thoroughly.
• Use C91.40 in cases of ongoing management and treatment failure.
• Ensure all relevant clinical data is included to support claims.
• Review coding guidelines to ensure compliance with billing practices.

Common CPT Pairings: