ICD-10 Code D58.0 | Hereditary spherocytosis Symptoms, Diagnosis, Billing

Hereditary spherocytosis is a genetic disorder characterized by the production of abnormally shaped red blood cells, leading to hemolytic anemia. This condition is clinically significant as it can result in severe anemia, jaundice, and splenomegaly. Accurate coding with ICD-10 Code D58.0 is essential for proper diagnosis, documentation, medical billing, and public health reporting.

What is ICD-10 Code D58.0 for Hereditary spherocytosis?

ICD-10 Code D58.0 specifically denotes hereditary spherocytosis, a condition where red blood cells are spherical rather than the typical biconcave shape. This abnormality leads to increased destruction of red blood cells, resulting in anemia. This code should be used in clinical documentation and billing when diagnosing patients with hereditary spherocytosis.

ICD-10 Code D58.0 – Clinical Definition and Explanation of Hereditary spherocytosis

Hereditary spherocytosis is primarily caused by genetic mutations affecting the proteins in the red blood cell membrane, leading to a loss of cell flexibility and increased fragility. This condition can progress to severe anemia and requires medical attention to manage symptoms and prevent complications.

Key Clinical Features:

• Spherically shaped red blood cells observed on peripheral blood smear.
• Symptoms of anemia including fatigue, pallor, and jaundice.
• Splenomegaly due to increased red blood cell destruction.
• Family history of hemolytic anemia or related conditions.

ICD-10 Code D58.0 for Hereditary spherocytosis – SOAP Notes & Clinical Use

ICD-10 Code D58.0 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to hereditary spherocytosis. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code D58.0 for Hereditary spherocytosis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D58.0 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of hereditary spherocytosis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D58.0 – Hereditary spherocytosis

Hereditary spherocytosis may require hospitalization for severe cases, particularly when complications arise. Treatment focuses on managing symptoms and preventing complications.

Antibiotic Therapy:

• Not applicable as hereditary spherocytosis is not an infectious condition.

Supportive Care:

• Folic acid supplementation to support red blood cell production.
• Blood transfusions in cases of severe anemia.
• Splenectomy may be indicated for symptomatic relief.

Infection Control:

• Monitor for infections post-splenectomy, as patients are at increased risk.
• Vaccination against encapsulated organisms is recommended.

How to Document Symptoms of Hereditary spherocytosis (ICD-10 D58.0) in SOAP Notes

Subjective:

• Patient reports fatigue and pallor.
• History of jaundice episodes.
• Family history of hereditary spherocytosis.
• Complaints of abdominal discomfort due to splenomegaly.

Objective:

• Pallor noted on physical examination.
• Splenomegaly detected on abdominal palpation.
• Laboratory results show elevated bilirubin and reticulocyte count.
• Peripheral blood smear reveals spherocytes.

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SOAP Note Guidelines for Diagnosing Hereditary spherocytosis (ICD-10 Code D58.0)

Assessment:

• Diagnosis of hereditary spherocytosis confirmed.
• Severity classified as moderate based on hemoglobin levels.
• Family history suggests genetic predisposition.
• Triggers include recent viral infection exacerbating anemia.

Plan:

• Initiate folic acid supplementation.
• Consider blood transfusion if hemoglobin drops below 8 g/dL.
• Educate patient on signs of infection and when to seek care.
• Schedule follow-up in 4 weeks to monitor hemoglobin levels.

Treatment & Plan Section for ICD-10 Code D58.0 – Hereditary spherocytosis

• First-line treatment includes folic acid supplementation.
• Blood transfusions may be necessary for severe anemia.
• Monitor for complications such as infections post-splenectomy.
• Patient education on managing symptoms and recognizing complications.

Using ICD-10 Code D58.0 for Hereditary spherocytosis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use D58.0 in all relevant encounters to support billing.
• Align treatment plans with clinical guidelines for justified billing.
• Document any related complications or comorbidities clearly.

Related ICD-10 Codes Often Used with Hereditary spherocytosis

• D58.1 – Hereditary elliptocytosis
• D58.8 – Other hereditary hemolytic anemias
• D59.0 – Acquired hemolytic anemia due to autoimmune disorders

ICD-10 Code D58.0 in Medical Billing and Insurance for Hereditary spherocytosis

ICD-10 Code D58.0 is critical in medical billing, particularly in hospital and emergency settings, to ensure accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings to support the use of D58.0.
• Use this code in inpatient and outpatient settings as applicable.
• Ensure that the patient's history and symptoms are clearly outlined in the chart.
• Include any related procedures or treatments in the billing documentation.

Common CPT Pairings: