ICD-10 Code C91.41 | Hairy cell leukemia, in remission Symptoms, Diagnosis, Billing

Hairy cell leukemia, in remission is a rare type of chronic leukemia characterized by the proliferation of abnormal B lymphocytes with hair-like projections. The condition is significant as it can lead to splenomegaly, cytopenias, and increased susceptibility to infections. Accurate coding with ICD-10 Code C91.41 ensures proper diagnosis, documentation, and billing, facilitating effective patient management and public health reporting.

What is ICD-10 Code C91.41 for Hairy cell leukemia, in remission?

ICD-10 Code C91.41 specifically denotes Hairy cell leukemia that is currently in remission. This condition arises from the accumulation of atypical B cells in the bone marrow and peripheral blood. This code should be utilized in clinical documentation and billing when a patient has achieved remission from the disease, reflecting the need for ongoing monitoring and management.

ICD-10 Code C91.41 – Clinical Definition and Explanation of Hairy cell leukemia, in remission

Hairy cell leukemia, in remission, is a hematological malignancy that results from the clonal proliferation of B lymphocytes. The disease typically progresses slowly and may require medical intervention to manage symptoms and prevent complications. Regular follow-up is essential to monitor for potential relapse.

Key Clinical Features:

• Splenomegaly
• Cytopenias (anemia, thrombocytopenia)
• Increased susceptibility to infections
• Fatigue and weakness

ICD-10 Code C91.41 for Hairy cell leukemia, in remission – SOAP Notes & Clinical Use

ICD-10 Code C91.41 is utilized in SOAP notes to document the patient's remission status, guiding clinical assessments and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management and accurate billing.

What Does ICD-10 Code C91.41 for Hairy cell leukemia, in remission Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C91.41 connects subjective patient reports and objective clinical findings to a formal diagnosis of Hairy cell leukemia in remission. This documentation is crucial for continuity of care, supporting billing processes, and meeting EHR standards.

Treatment Options for ICD-10 Code C91.41 – Hairy cell leukemia, in remission

Management of Hairy cell leukemia in remission focuses on monitoring and supportive care. Hospitalization may be necessary for complications or infections.

Antibiotic Therapy:

• Clindamycin (first-line, 7-10 days)
• Ciprofloxacin (alternative, 7-14 days)
• Vancomycin (if severe infection, duration based on clinical response)

Supportive Care:

• Regular blood count monitoring
• Management of splenomegaly
• Symptomatic treatment for fatigue
• Vaccination against infections

Infection Control:

• Strict hand hygiene
• Isolation precautions during outbreaks
• Prompt treatment of any febrile episodes

How to Document Symptoms of Hairy cell leukemia, in remission (ICD-10 C91.41) in SOAP Notes

Subjective:

• Patient reports fatigue and weakness
• No recent infections or fever
• History of splenomegaly
• Denies any new symptoms

Objective:

• Physical exam shows splenomegaly
• CBC reveals mild anemia
• No leukocytosis or thrombocytopenia
• Vital signs stable

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SOAP Note Guidelines for Diagnosing Hairy cell leukemia, in remission (ICD-10 Code C91.41)

Assessment:

• Diagnosis: Hairy cell leukemia, in remission
• ICD-10 Code: C91.41
• No current symptoms of relapse
• Monitor for potential complications

Plan:

• Continue regular follow-up appointments
• Educate patient on signs of relapse
• Monitor blood counts every 3-6 months
• Consider referral to hematology for ongoing management

Treatment & Plan Section for ICD-10 Code C91.41 – Hairy cell leukemia, in remission

• Monitor blood counts regularly
• Educate on infection prevention strategies
• Provide supportive care for symptoms
• Schedule follow-up visits every 3-6 months

Using ICD-10 Code C91.41 for Hairy cell leukemia, in remission in Billing & SOAP Note Compliance

• Ensure accurate documentation of remission status in SOAP notes
• Use C91.41 for billing during follow-up visits
• Document any complications or infections separately
• Align treatment plans with clinical guidelines for justified billing

Related ICD-10 Codes Often Used with Hairy cell leukemia, in remission

• C91.40 – Hairy cell leukemia, unspecified

ICD-10 Code C91.41 in Medical Billing and Insurance for Hairy cell leukemia, in remission

ICD-10 Code C91.41 is essential for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document remission status clearly in patient records
• Use C91.41 for follow-up visits and monitoring
• Ensure all relevant symptoms and treatments are recorded
• Maintain compliance with coding guidelines for accurate claims

Common CPT Pairings: