ICD-10 Code D57.04 | Hb-SS disease with dactylitis Symptoms, Diagnosis, Billing

Hb-SS disease with dactylitis is a severe form of sickle cell disease characterized by the presence of hemoglobin S. Dactylitis, or hand-foot syndrome, is a common complication in children, presenting as painful swelling of the fingers and toes. Accurate coding with ICD-10 Code D57.04 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 D57.04 for Hb-SS disease with dactylitis?

ICD-10 Code D57.04 specifically denotes Hb-SS disease with dactylitis, a condition resulting from the sickling of red blood cells leading to vaso-occlusive crises. This code should be used when documenting cases of dactylitis in patients with Hb-SS disease, facilitating accurate clinical documentation and billing processes.

ICD-10 Code D57.04 – Clinical Definition and Explanation of Hb-SS disease with dactylitis

Hb-SS disease with dactylitis is caused by a genetic mutation leading to abnormal hemoglobin production. The condition progresses with episodes of pain and swelling due to blood flow obstruction in small vessels. Prompt medical attention is necessary to manage symptoms and prevent complications.

Key Clinical Features:

• Painful swelling of fingers and toes (dactylitis)
• Increased risk of infections due to splenic dysfunction
• Episodes of acute pain crises
• Anemia and fatigue due to hemolysis

ICD-10 Code D57.04 for Hb-SS disease with dactylitis – SOAP Notes & Clinical Use

ICD-10 Code D57.04 is utilized in SOAP notes to document the presence of dactylitis in patients with Hb-SS disease. This code aids in capturing symptoms, assessments, and treatment plans, relevant in both acute and chronic care settings.

What Does ICD-10 Code D57.04 for Hb-SS disease with dactylitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D57.04 connects subjective reports of pain and swelling with objective clinical findings, establishing a formal diagnosis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D57.04 – Hb-SS disease with dactylitis

Management of Hb-SS disease with dactylitis requires a multifaceted approach to alleviate symptoms and prevent complications.

Antibiotic Therapy:

• Penicillin prophylaxis for children under 5 years old
• Ceftriaxone for acute infections
• Alternatives include azithromycin for penicillin-allergic patients

Supportive Care:

• Hydration to prevent vaso-occlusive crises
• Pain management with NSAIDs or opioids as needed
• Regular monitoring for signs of infection

Infection Control:

• Vaccination against pneumococcus, meningococcus, and influenza
• Education on hand hygiene and avoiding sick contacts
• Prompt treatment of febrile episodes

How to Document Symptoms of Hb-SS disease with dactylitis (ICD-10 D57.04) in SOAP Notes

Subjective:

• Patient reports swelling and pain in hands and feet.
• History of recurrent dactylitis episodes.
• Complaints of fatigue and difficulty in daily activities.
• Family history of sickle cell disease.

Objective:

• Swelling noted in fingers and toes on examination.
• Vital signs: temperature 101°F, pulse 110 bpm.
• Laboratory results show low hemoglobin levels.
• Signs of dehydration observed.

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SOAP Note Guidelines for Diagnosing Hb-SS disease with dactylitis (ICD-10 Code D57.04)

Assessment:

• Diagnosis: Hb-SS disease with dactylitis, moderate severity.
• ICD-10 Code: D57.04.
• Triggers include dehydration and infection.
• Patient exhibits signs of acute pain crisis.

Plan:

• Administer IV fluids for hydration.
• Prescribe pain management regimen including NSAIDs.
• Educate patient on hydration and infection prevention.
• Schedule follow-up in one week to reassess.

Treatment & Plan Section for ICD-10 Code D57.04 – Hb-SS disease with dactylitis

• First-line pharmacologic treatments include NSAIDs for pain relief.
• Non-pharmacologic strategies involve hydration and rest.
• Monitoring includes regular hemoglobin checks and pain assessments.
• Follow-up appointments to evaluate treatment efficacy and adjust as needed.

Using ICD-10 Code D57.04 for Hb-SS disease with dactylitis in Billing & SOAP Note Compliance

• Select accurate subcodes based on clinical severity or complications.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Commonly billed CPT codes include office visits and lab tests related to sickle cell management.

Related ICD-10 Codes Often Used with Hb-SS disease with dactylitis

• D57.00 – Sickle-cell disease, unspecified
• D57.01 – Sickle-cell disease with crisis
• D57.02 – Sickle-cell disease with acute chest syndrome
• D57.03 – Sickle-cell disease with splenic sequestration

ICD-10 Code D57.04 in Medical Billing and Insurance for Hb-SS disease with dactylitis

ICD-10 Code D57.04 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant symptoms and treatment plans to support claims.
• Use this code in conjunction with appropriate CPT codes for comprehensive billing.
• Ensure that documentation reflects the severity and complexity of the condition.

Common CPT Pairings: