ICD-10 Code D57.411 | Sickle-cell thalassemia, unsp, with acute chest syndrome Symptoms, Diagnosis, Billing

Sickle-cell thalassemia, unsp, with acute chest syndrome is a serious complication of sickle cell disease characterized by the presence of sickle-shaped red blood cells and thalassemia traits. This condition can lead to acute chest syndrome, a life-threatening complication marked by chest pain, fever, and respiratory distress. Accurate coding with ICD-10 Code D57.411 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 D57.411 for Sickle-cell thalassemia, unsp, with acute chest syndrome?

ICD-10 Code D57.411 represents Sickle-cell thalassemia, unsp, with acute chest syndrome, a condition that arises from the combination of sickle cell disease and thalassemia, leading to acute chest syndrome. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of acute chest syndrome, such as chest pain and respiratory distress, particularly in the context of underlying sickle cell pathology.

ICD-10 Code D57.411 – Clinical Definition and Explanation of Sickle-cell thalassemia, unsp, with acute chest syndrome

Sickle-cell thalassemia, unsp, with acute chest syndrome is caused by the combination of sickle cell disease and thalassemia, leading to abnormal hemoglobin production and resultant vaso-occlusive crises. This condition can progress rapidly, necessitating immediate medical attention due to the risk of severe respiratory complications.

Key Clinical Features:

• Acute chest pain and discomfort
• Fever and chills
• Cough and difficulty breathing
• Hypoxemia and tachypnea

ICD-10 Code D57.411 for Sickle-cell thalassemia, unsp, with acute chest syndrome – SOAP Notes & Clinical Use

ICD-10 Code D57.411 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to acute chest syndrome in the context of sickle-cell thalassemia. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code D57.411 for Sickle-cell thalassemia, unsp, with acute chest syndrome Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D57.411 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of acute chest syndrome. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D57.411 – Sickle-cell thalassemia, unsp, with acute chest syndrome

The management of Sickle-cell thalassemia, unsp, with acute chest syndrome often requires hospitalization due to the potential for rapid deterioration. Treatment focuses on symptom relief and preventing complications.

Antibiotic Therapy:

• First-line: Ceftriaxone 1-2 g IV every 12-24 hours for 7-10 days
• Alternative: Azithromycin 500 mg IV on day 1, then 250 mg daily for 4 days

Supportive Care:

• Oxygen therapy to maintain adequate oxygen saturation
• Pain management with opioids as needed
• Hydration with IV fluids to prevent vaso-occlusive crises

Infection Control:

• Implement standard precautions to prevent infection spread
• Isolate patients with suspected infectious causes of acute chest syndrome

How to Document Symptoms of Sickle-cell thalassemia, unsp, with acute chest syndrome (ICD-10 D57.411) in SOAP Notes

Subjective:

• Patient reports sudden onset of chest pain, rated 8/10
• History of fever and chills over the past 24 hours
• Increased shortness of breath with minimal exertion
• Known sickle cell disease with previous episodes of acute chest syndrome

Objective:

• Vital signs: BP 110/70 mmHg, HR 120 bpm, RR 28 breaths/min, SpO2 88% on room air
• Auscultation reveals decreased breath sounds bilaterally
• Chest X-ray shows infiltrates consistent with acute chest syndrome
• Laboratory results indicate elevated white blood cell count and anemia

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SOAP Note Guidelines for Diagnosing Sickle-cell thalassemia, unsp, with acute chest syndrome (ICD-10 Code D57.411)

Assessment:

• Diagnosis: Sickle-cell thalassemia, unsp, with acute chest syndrome, moderate severity
• ICD-10 Code: D57.411
• Triggers: Recent respiratory infection and dehydration
• Complications: Risk of respiratory failure and sepsis

Plan:

• Initiate IV fluids and oxygen therapy
• Administer pain management with morphine as needed
• Start antibiotic therapy as per guidelines
• Schedule follow-up chest X-ray and monitor vital signs closely

Treatment & Plan Section for ICD-10 Code D57.411 – Sickle-cell thalassemia, unsp, with acute chest syndrome

• First-line pharmacologic treatments include IV antibiotics and analgesics.
• Non-pharmacologic strategies involve hydration and oxygen supplementation.
• Monitoring practices include regular assessment of vital signs and oxygen saturation.
• Follow-up should include repeat imaging and evaluation of clinical status.

Using ICD-10 Code D57.411 for Sickle-cell thalassemia, unsp, with acute chest syndrome 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 those for emergency evaluation and management.

Related ICD-10 Codes Often Used with Sickle-cell thalassemia, unsp, with acute chest syndrome

• D57.1 – Sickle-cell disease with crisis
• D57.3 – Sickle-cell disease with splenic sequestration

ICD-10 Code D57.411 in Medical Billing and Insurance for Sickle-cell thalassemia, unsp, with acute chest syndrome

ICD-10 Code D57.411 is critical in medical billing, particularly in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Ensure documentation includes detailed clinical findings and treatment plans.
• Use this code in acute care settings where immediate intervention is required.
• Highlight key chart elements such as vital signs and lab results to support claims.
• Document any complications or comorbidities that may affect billing.

Common CPT Pairings: