ICD-10 Code D57.02 | Hb-SS disease with splenic sequestration Symptoms, Diagnosis, Billing

Hb-SS disease with splenic sequestration is a severe form of sickle cell disease characterized by the abnormal sickling of red blood cells, leading to vaso-occlusive crises and splenic dysfunction. This condition can result in acute splenic sequestration, which is a medical emergency requiring prompt diagnosis and treatment. The ICD-10 Code D57.02 facilitates accurate documentation, billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this serious condition.

What is ICD-10 Code D57.02 for Hb-SS disease with splenic sequestration?

ICD-10 Code D57.02 specifically denotes Hb-SS disease with splenic sequestration, a complication of sickle cell disease where sickled red blood cells obstruct blood flow in the spleen, leading to splenic enlargement and potential rupture. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of splenic sequestration, ensuring appropriate care and resource allocation.

ICD-10 Code D57.02 – Clinical Definition and Explanation of Hb-SS disease with splenic sequestration

Hb-SS disease with splenic sequestration occurs due to the accumulation of sickled red blood cells in the spleen, causing acute splenic enlargement and dysfunction. This condition can lead to severe complications, including splenic infarction and increased risk of infections. Immediate medical attention is crucial to prevent life-threatening outcomes.

Key Clinical Features:

• Acute abdominal pain due to splenic enlargement
• Signs of anemia, such as fatigue and pallor
• Increased susceptibility to infections, particularly encapsulated organisms
• Possible jaundice from hemolysis

ICD-10 Code D57.02 for Hb-SS disease with splenic sequestration – SOAP Notes & Clinical Use

ICD-10 Code D57.02 is utilized in SOAP notes to document the clinical presentation, assessment, and management of patients experiencing splenic sequestration due to Hb-SS disease. This code is essential for both acute and chronic care settings, ensuring comprehensive patient records and facilitating appropriate treatment plans.

What Does ICD-10 Code D57.02 for Hb-SS disease with splenic sequestration Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D57.02 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Hb-SS disease with splenic sequestration. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D57.02 – Hb-SS disease with splenic sequestration

Management of Hb-SS disease with splenic sequestration often requires urgent intervention to prevent complications. Hospitalization is typically necessary for monitoring and treatment.

Antibiotic Therapy:

• First-line: Penicillin prophylaxis (oral or IV) for children and adults at risk
• Alternative: Ceftriaxone for acute infections
• Duration: Typically 7-10 days for acute infections

Supportive Care:

• Hydration to prevent further sickling
• Pain management with analgesics
• Blood transfusions if indicated to manage severe anemia

Infection Control:

• Strict hand hygiene practices
• Vaccination against pneumococcus, meningococcus, and influenza
• Isolation precautions during outbreaks of infections

How to Document Symptoms of Hb-SS disease with splenic sequestration (ICD-10 D57.02) in SOAP Notes

Subjective:

• Patient reports severe left upper quadrant pain.
• History of recurrent splenic sequestration episodes.
• Complaints of fatigue and weakness.
• Recent fever and chills noted.

Objective:

• Physical exam reveals splenomegaly.
• Vital signs: tachycardia, low-grade fever.
• Laboratory findings: low hemoglobin, elevated reticulocyte count.
• Possible jaundice observed on examination.

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SOAP Note Guidelines for Diagnosing Hb-SS disease with splenic sequestration (ICD-10 Code D57.02)

Assessment:

• Diagnosis: Hb-SS disease with splenic sequestration, acute episode.
• ICD-10 Code: D57.02.
• Triggers: Recent infection and dehydration.
• Severity: Moderate to severe based on clinical presentation.

Plan:

• Initiate IV hydration and pain management.
• Administer blood transfusion as needed.
• Start prophylactic antibiotics.
• Schedule follow-up in 1 week to reassess splenic function.

Treatment & Plan Section for ICD-10 Code D57.02 – Hb-SS disease with splenic sequestration

• First-line pharmacologic treatment includes hydration and analgesics.
• Consider blood transfusions for severe anemia.
• Educate on recognizing early signs of splenic sequestration.
• Monitor hemoglobin levels and splenic size regularly.

Using ICD-10 Code D57.02 for Hb-SS disease with splenic sequestration in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings.
• Document symptoms clearly under Subjective (S) and Objective (O) sections.
• Ensure treatment plans align with clinical guidelines for justified billing.
• Include relevant CPT codes for services rendered during the visit.

Related ICD-10 Codes Often Used with Hb-SS disease with splenic sequestration

• D57.01 – Hb-SS disease without splenic sequestration

ICD-10 Code D57.02 in Medical Billing and Insurance for Hb-SS disease with splenic sequestration

ICD-10 Code D57.02 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure accurate documentation of clinical findings to support the use of D57.02.
• Use this code in conjunction with appropriate CPT codes for comprehensive billing.
• Document all relevant patient history and treatment plans to justify claims.
• Review payer guidelines for specific billing requirements related to this code.

Common CPT Pairings: