CODING SNAPSHOT – Anemia
HISTORY OF PRESENT ILLNESS: This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone. Overall, she tells me that now she feels quite well. Repeat CBC showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.
CURRENT MEDICATIONS: Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. Status post tonsillectomy.
2. Status post hysterectomy.
3. Status post bilateral cataract surgery.
4. Esophageal stricture status post dilatation approximately four times.
SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.
VIT: Height 167 cm, weight 66 kg, blood pressure 122/70, pulse 84, and temperature is 98.9.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Idiopathicaplastic anemia. I am going to repeat her CMP today to assess her kidney function. We will continue with monthly CBCs for now and I will see her again in one month.
ICD-10-CM Code(s): D61.3 Idiopathic aplastic anemia
Rationale: The codes for anemia in ICD-10-CM are located in code blocks D50-D53 for nutritional anemias, D55-D59 for hemolytic anemia, and D60-D64 for aplastic and other anemias and other bone marrow failure syndromes. Aplastic anemia is located in code block D60-D64 with the codes broken down by type. Idiopathic means that the cause is unknown or arises suddenly. Pancytopenia is an abnormal reduction in the number of red blood cells, white blood cells, and blood platelets in the blood. It is a common sign/symptom/manifestation of aplastic anemia, so it would not be reported separately.