ICD-10 Code C91.42 | Hairy cell leukemia, in relapse Symptoms, Diagnosis, Billing

Hairy cell leukemia, in relapse is a hematological malignancy characterized by the proliferation of atypical B lymphocytes with hairy projections. This condition is clinically significant as it indicates a return of the disease after a period of remission, necessitating prompt medical intervention. The ICD-10 Code C91.42 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage patient care.

What is ICD-10 Code C91.42 for Hairy cell leukemia, in relapse?

ICD-10 Code C91.42 specifically denotes Hairy cell leukemia that has relapsed after treatment. This condition arises from the malignant transformation of B lymphocytes, leading to splenomegaly, cytopenias, and increased susceptibility to infections. This code should be used in clinical documentation and billing when a patient presents with signs of relapse, ensuring appropriate treatment and follow-up.

ICD-10 Code C91.42 – Clinical Definition and Explanation of Hairy cell leukemia, in relapse

Hairy cell leukemia, in relapse occurs when previously treated patients experience a resurgence of the disease, often after a period of remission. The condition requires immediate medical attention due to its potential complications and impact on the patient's health. Relapse may be indicated by worsening symptoms or laboratory findings.

Key Clinical Features:

• Presence of splenomegaly and lymphadenopathy.
• Cytopenias, including anemia, thrombocytopenia, and leukopenia.
• Increased susceptibility to infections due to immunosuppression.
• Elevated levels of circulating hairy cells in peripheral blood smears.

ICD-10 Code C91.42 for Hairy cell leukemia, in relapse – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code C91.42 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to the relapse of Hairy cell leukemia. This code is essential for both acute and chronic care settings, ensuring comprehensive patient management and accurate billing.

What Does ICD-10 Code C91.42 for Hairy cell leukemia, in relapse Mean in SOAP Notes?

ICD-10 Code C91.42 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Hairy cell leukemia in relapse. This code is crucial for ensuring continuity of care, supporting billing processes, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code C91.42 – Hairy cell leukemia, in relapse

The management of Hairy cell leukemia, in relapse often necessitates hospitalization for intensive treatment. Therapeutic approaches may include chemotherapy and supportive care to manage symptoms and prevent complications.

Antibiotic Therapy:

• First-line: Cladribine (2-CdA) for chemotherapy.
• Alternative: Pentostatin for patients intolerant to first-line therapy.
• Duration: Treatment duration varies based on response and tolerance.

Supportive Care:

• Transfusions for anemia and thrombocytopenia.
• Antibiotics for infections as needed.
• Growth factors to stimulate blood cell production.

Infection Control:

• Strict hand hygiene and isolation precautions during outbreaks.
• Prophylactic antibiotics in high-risk patients.
• Monitoring for signs of infection.

How to Document Symptoms of Hairy cell leukemia, in relapse (ICD-10 C91.42) in SOAP Notes

Subjective:

• Patient reports increased fatigue and weakness.
• History of recurrent infections over the past month.
• Notable weight loss and night sweats.
• Patient expresses concern about swollen lymph nodes.

Objective:

• Physical examination reveals splenomegaly.
• CBC shows anemia, thrombocytopenia, and leukopenia.
• Peripheral blood smear demonstrates hairy cells.
• Vital signs stable with no fever.

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SOAP Note Guidelines for Diagnosing Hairy cell leukemia, in relapse (ICD-10 Code C91.42)

Assessment:

• Diagnosis: Hairy cell leukemia, in relapse (ICD-10 C91.42).
• Severity: Moderate, with significant cytopenias.
• Triggers: Previous treatment response and potential infection.
• Complications: Risk of severe infections and bleeding.

Plan:

• Initiate chemotherapy with Cladribine.
• Monitor blood counts weekly during treatment.
• 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 C91.42 – Hairy cell leukemia, in relapse

• First-line treatment with Cladribine or Pentostatin.
• Supportive care including blood transfusions and antibiotics.
• Regular monitoring of blood counts and symptoms.
• Patient education on infection prevention and symptom management.

Using ICD-10 Code C91.42 for Hairy cell leukemia, in relapse in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and treatment plans.
• Use C91.42 in settings of acute care and follow-up visits.
• Align treatment plans with clinical guidelines for justified billing.
• Document all relevant findings under Subjective (S) and Objective (O) sections.

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

• C91.41 – Hairy cell leukemia, in remission
• C91.00 – Acute lymphoblastic leukemia, unspecified
• C91.10 – Chronic lymphocytic leukemia, unspecified

ICD-10 Code C91.42 in Medical Billing and Insurance for Hairy cell leukemia, in relapse

ICD-10 Code C91.42 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and treatment details.
• Use C91.42 in acute care settings to support claims.
• Ensure compliance with coding guidelines for accurate billing.
• Include all pertinent clinical findings in the patient's chart.

Common CPT Pairings: