ICD-10 Code D45 | Polycythemia vera Symptoms, Diagnosis, Billing

Polycythemia vera is a myeloproliferative neoplasm characterized by the overproduction of red blood cells, often accompanied by increased white blood cells and platelets. This condition can lead to complications such as thrombosis and hemorrhage. Accurate coding with ICD-10 Code D45 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and resources are allocated effectively.

What is ICD-10 Code D45 for Polycythemia vera?

ICD-10 Code D45 represents Polycythemia vera, a chronic blood disorder resulting from the overproduction of red blood cells due to a mutation in the JAK2 gene. This code should be used in clinical documentation and billing when diagnosing patients with this condition, facilitating appropriate treatment and management strategies.

ICD-10 Code D45 – Clinical Definition and Explanation of Polycythemia vera

Polycythemia vera is primarily caused by a mutation in the JAK2 gene, leading to uncontrolled proliferation of hematopoietic stem cells. This condition can progress to serious complications, including thrombosis and myelofibrosis, necessitating medical intervention. Early diagnosis and management are crucial to prevent adverse outcomes.

Key Clinical Features:

• Elevated hemoglobin and hematocrit levels.
• Symptoms may include headaches, dizziness, and visual disturbances.
• Increased risk of thrombotic events such as stroke or myocardial infarction.
• Splenomegaly may be present on physical examination.

ICD-10 Code D45 for Polycythemia vera – SOAP Notes & Clinical Use

ICD-10 Code D45 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation that supports clinical decision-making and billing processes.

What Does ICD-10 Code D45 for Polycythemia vera Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D45 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Polycythemia vera. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D45 – Polycythemia vera

Polycythemia vera requires prompt medical attention to manage symptoms and prevent complications. Treatment may include phlebotomy and medication to reduce blood viscosity.

Antibiotic Therapy:

Supportive Care:

• Regular phlebotomy to reduce red blood cell mass.
• Hydroxyurea to decrease blood cell production.
• Low-dose aspirin to reduce thrombotic risk.

Infection Control:

How to Document Symptoms of Polycythemia vera (ICD-10 D45) in SOAP Notes

Subjective:

• Patient reports persistent headaches and dizziness.
• Complaints of fatigue and weakness.
• History of visual disturbances.
• No recent infections or significant weight changes.

Objective:

• Elevated hemoglobin level of 18 g/dL.
• Hematocrit at 55%.
• Blood pressure 130/80 mmHg.
• Splenomegaly noted on physical examination.

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SOAP Note Guidelines for Diagnosing Polycythemia vera (ICD-10 Code D45)

Assessment:

• Diagnosis of Polycythemia vera (ICD-10 D45) confirmed.
• Severity classified as moderate based on hemoglobin levels.
• Contributing factors include age and genetic predisposition.

Plan:

• Initiate phlebotomy to reduce hematocrit levels.
• Consider hydroxyurea therapy for long-term management.
• Educate patient on recognizing symptoms of thrombosis.
• Schedule follow-up in 3 months for reassessment.

Treatment & Plan Section for ICD-10 Code D45 – Polycythemia vera

• Phlebotomy as first-line treatment to manage elevated red blood cell mass.
• Hydroxyurea for patients with high thrombotic risk.
• Patient education on lifestyle modifications to reduce cardiovascular risk.
• Regular monitoring of blood counts and symptoms.

Using ICD-10 Code D45 for Polycythemia vera in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings under Subjective (S) and Objective (O).
• Use ICD-10 Code D45 to support billing for laboratory tests and treatments.
• Align treatment plans with clinical guidelines to justify billing.
• Document patient education and follow-up plans to enhance care continuity.

Related ICD-10 Codes Often Used with Polycythemia vera

• D47.1 – Essential thrombocythemia

ICD-10 Code D45 in Medical Billing and Insurance for Polycythemia vera

ICD-10 Code D45 is critical in medical billing, particularly in hospital and outpatient settings.

Billing Notes:

• Document all relevant clinical findings to support the use of D45.
• Use D45 in conjunction with laboratory codes for blood tests.
• Ensure that treatment plans are clearly outlined in the medical record.

Common CPT Pairings: