ICD-10 Code D57.412 | Sickle-cell thalassemia, unsp, with splenic sequestration Symptoms, Diagnosis, Billing

Sickle-cell thalassemia, unspecified, with splenic sequestration is a hematological condition characterized by the presence of both sickle cell disease and thalassemia, leading to abnormal hemoglobin production. This condition can result in splenic sequestration crises, where red blood cells become trapped in the spleen, causing acute splenic enlargement and pain. Accurate coding with ICD-10 Code D57.412 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat affected patients.

What is ICD-10 Code D57.412 for Sickle-cell thalassemia, unsp, with splenic sequestration?

ICD-10 Code D57.412 represents sickle-cell thalassemia, unspecified, with splenic sequestration. This code is used to document cases where patients experience complications related to both sickle cell disease and thalassemia, specifically involving splenic sequestration. It should be applied in clinical documentation and billing when patients present with symptoms indicative of splenic sequestration, ensuring accurate representation of their medical condition.

ICD-10 Code D57.412 – Clinical Definition and Explanation of Sickle-cell thalassemia, unsp, with splenic sequestration

Sickle-cell thalassemia, unspecified, with splenic sequestration is caused by genetic mutations affecting hemoglobin production, leading to the formation of sickle-shaped red blood cells. These abnormal cells can obstruct blood flow, particularly in the spleen, resulting in splenic sequestration crises. This condition requires prompt medical attention to prevent severe complications such as splenic rupture and severe anemia.

Key Clinical Features:

• Acute splenic enlargement and pain due to trapped red blood cells.
• Increased risk of infections due to compromised splenic function.
• Symptoms of anemia, including fatigue, pallor, and shortness of breath.
• Potential for vaso-occlusive crises leading to acute pain episodes.

ICD-10 Code D57.412 for Sickle-cell thalassemia, unsp, with splenic sequestration – SOAP Notes & Clinical Use

ICD-10 Code D57.412 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of patients with sickle-cell thalassemia and splenic sequestration. This code aids in capturing the patient's symptoms, guiding clinical assessments, and formulating treatment plans in both acute and chronic care settings.

What Does ICD-10 Code D57.412 for Sickle-cell thalassemia, unsp, with splenic sequestration Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D57.412 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of sickle-cell thalassemia with splenic sequestration. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D57.412 – Sickle-cell thalassemia, unsp, with splenic sequestration

Management of sickle-cell thalassemia with splenic sequestration often necessitates hospitalization due to the risk of severe complications. Treatment focuses on alleviating symptoms and preventing further crises.

Antibiotic Therapy:

• First-line: Penicillin prophylaxis for children and adults at risk.
• Alternative: Ceftriaxone for acute infections.
• Duration: Typically 10-14 days for acute infections.

Supportive Care:

• Hydration and pain management with analgesics.
• Blood transfusions in cases of severe anemia.
• Monitoring for signs of infection and splenic function.

Infection Control:

• Implement standard precautions to prevent infection spread.
• Educate patients on recognizing signs of infection.
• Vaccination against pneumococcus, meningococcus, and influenza.

How to Document Symptoms of Sickle-cell thalassemia, unsp, with splenic sequestration (ICD-10 D57.412) in SOAP Notes

Subjective:

• Patient reports severe left upper quadrant pain.
• History of recurrent splenic sequestration episodes.
• Complaints of fatigue and shortness of breath.
• Recent fever and chills suggestive of infection.

Objective:

• Physical exam reveals splenomegaly.
• Vital signs: Temperature 101°F, heart rate 110 bpm.
• Laboratory findings: Low hemoglobin level, elevated reticulocyte count.
• Imaging shows enlarged spleen on ultrasound.

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SOAP Note Guidelines for Diagnosing Sickle-cell thalassemia, unsp, with splenic sequestration (ICD-10 Code D57.412)

Assessment:

• Diagnosis: Sickle-cell thalassemia, unspecified, with splenic sequestration (ICD-10 D57.412).
• Severity: Moderate to severe based on clinical presentation.
• Triggers: Recent infection and dehydration contributing to splenic sequestration.
• Complications: Risk of splenic rupture and severe anemia.

Plan:

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

Treatment & Plan Section for ICD-10 Code D57.412 – Sickle-cell thalassemia, unsp, with splenic sequestration

• First-line pharmacologic treatments include analgesics and hydration.
• Non-pharmacologic strategies involve patient education on recognizing symptoms.
• Monitoring practices include regular hemoglobin checks and splenic assessments.
• Follow-up appointments should be scheduled to evaluate treatment efficacy.

Using ICD-10 Code D57.412 for Sickle-cell thalassemia, unsp, with splenic sequestration 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.
• Only list CPT codes that are commonly billed with ICD-10 Code D57.412 based on standard medical coding practices.

Related ICD-10 Codes Often Used with Sickle-cell thalassemia, unsp, with splenic sequestration

• D57.411 – Sickle-cell thalassemia, unsp, without splenic sequestration
• D57.413 – Sickle-cell thalassemia, unsp, with splenic sequestration, recurrent
• D56.9 – Thalassemia, unspecified

ICD-10 Code D57.412 in Medical Billing and Insurance for Sickle-cell thalassemia, unsp, with splenic sequestration

ICD-10 Code D57.412 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure comprehensive documentation of symptoms and treatment to support claims.
• Use this code in acute care settings where splenic sequestration is diagnosed.
• Highlight key chart elements such as lab results and imaging findings.
• Maintain accurate coding to facilitate reimbursement and compliance.

Common CPT Pairings: