ICD-10 Code D69.41 | Evans syndrome Symptoms, Diagnosis, Billing

Evans syndrome is a rare autoimmune disorder characterized by the simultaneous occurrence of autoimmune hemolytic anemia and immune thrombocytopenic purpura. This condition can lead to significant morbidity due to the risk of severe anemia and bleeding. Accurate coding with ICD-10 Code D69.41 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 D69.41 for Evans syndrome?

ICD-10 Code D69.41 represents Evans syndrome, which involves the combination of autoimmune hemolytic anemia and immune thrombocytopenic purpura. This code should be used in clinical documentation and billing when a patient presents with these overlapping conditions, facilitating accurate diagnosis and treatment planning.

ICD-10 Code D69.41 – Clinical Definition and Explanation of Evans syndrome

Evans syndrome is primarily caused by an autoimmune response where the body's immune system mistakenly attacks its own red blood cells and platelets. This condition can lead to severe complications, including life-threatening anemia and bleeding, necessitating prompt medical attention.

Key Clinical Features:

• Presence of both autoimmune hemolytic anemia and thrombocytopenia.
• Symptoms may include fatigue, pallor, easy bruising, and petechiae.
• Can occur in isolation or as part of other autoimmune disorders.
• Requires careful monitoring and management to prevent complications.

ICD-10 Code D69.41 for Evans syndrome – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code D69.41 is utilized to document the diagnosis of Evans syndrome, aiding in the assessment of symptoms, treatment plans, and patient management in both acute and chronic care settings.

What Does ICD-10 Code D69.41 for Evans syndrome Mean in SOAP Notes?

ICD-10 Code D69.41 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Evans syndrome, ensuring continuity of care and supporting accurate billing and EHR documentation.

Treatment Options for ICD-10 Code D69.41 – Evans syndrome

Evans syndrome often requires urgent medical intervention due to the risk of severe complications. Treatment may include immunosuppressive therapies and supportive care.

Antibiotic Therapy:

• Not applicable as Evans syndrome is not an infectious condition.

Supportive Care:

• Blood transfusions for severe anemia.
• Platelet transfusions if significant bleeding occurs.
• Corticosteroids to reduce immune response.

Infection Control:

• Standard precautions to prevent infections in immunocompromised patients.

How to Document Symptoms of Evans syndrome (ICD-10 D69.41) in SOAP Notes

Subjective:

• Patient reports fatigue and weakness.
• History of easy bruising and frequent nosebleeds.
• Complaints of pallor and shortness of breath.

Objective:

• Pallor noted on physical examination.
• Low hemoglobin and hematocrit levels on CBC.
• Thrombocytopenia observed in lab results.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Evans syndrome (ICD-10 Code D69.41)

Assessment:

• Diagnosis of Evans syndrome confirmed.
• Severity classified as moderate based on lab results.
• Contributing factors include autoimmune response.

Plan:

• Initiate corticosteroid therapy.
• Consider referral to hematology for further management.
• Monitor hemoglobin and platelet levels regularly.
• Educate patient on signs of bleeding and when to seek care.

Treatment & Plan Section for ICD-10 Code D69.41 – Evans syndrome

• First-line treatment includes corticosteroids to manage autoimmune response.
• Supportive care with blood transfusions as needed.
• Regular monitoring of blood counts to assess treatment efficacy.
• Patient education on recognizing symptoms of complications.

Using ICD-10 Code D69.41 for Evans syndrome in Billing & SOAP Note Compliance

• Ensure clear documentation of symptoms and lab findings under Subjective (S) and Objective (O).
• Use D69.41 in conjunction with appropriate treatment codes for accurate billing.
• Document patient education and follow-up plans to support claims.
• Align treatment plans with clinical guidelines to justify billing.

Related ICD-10 Codes Often Used with Evans syndrome

• D69.3 – Immune thrombocytopenic purpura
• D50.9 – Iron deficiency anemia, unspecified

ICD-10 Code D69.41 in Medical Billing and Insurance for Evans syndrome

ICD-10 Code D69.41 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the claim.
• Use D69.41 in appropriate settings to reflect the complexity of care.
• Ensure compliance with coding guidelines to avoid denials.
• Include detailed notes on patient education and follow-up.

Common CPT Pairings: