ICD-10 Coding for Myelodysplastic Syndromes(D46.9, D46.1, D46.2)
Complete ICD-10-CM coding and documentation guide for Myelodysplastic Syndromes. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Myelodysplastic Syndromes
D46.0-D46.ZPrimary Range
Myelodysplastic syndromes
This range covers all subtypes of myelodysplastic syndromes, including unspecified and specific variants.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| D46.9 | Myelodysplastic syndrome, unspecified | Use when MDS is diagnosed but specific subtype details are not available. |
|
| D46.1 | Refractory anemia with ring sideroblasts | Use when bone marrow biopsy confirms ≥15% ring sideroblasts. |
|
| D46.2 | Refractory anemia with excess blasts | Use when bone marrow biopsy shows 5-19% blasts. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for myelodysplastic syndrome
Essential facts and insights about Myelodysplastic Syndromes
Primary ICD-10-CM Codes for myelodysplasia syndrome
Decision Criteria
clinical Criteria
- Diagnosis of MDS without specific subtype characterization
coding Criteria
- No specific genetic or cytogenetic testing results available
Applicable To
- Myelodysplastic syndrome NOS
Excludes
- Acute myeloid leukemia (C92.0-)
Clinical Validation Requirements
- Diagnosis of MDS without specific subtype characterization
- Lack of genetic or cytogenetic testing results
Code-Specific Risks
- Overuse of unspecified code when more specific information is available.
Coding Notes
- Ensure documentation supports the use of an unspecified code by confirming the absence of specific subtype details.
D46.1 - Refractory anemia with ring sideroblasts
Use when bone marrow biopsy confirms ≥15% ring sideroblasts.
Applicable To
- Refractory anemia with ringed sideroblasts
Excludes
- Sideroblastic anemia (D64.0)
Clinical Validation Requirements
- Bone marrow report showing ≥15% ring sideroblasts
- Anemia unresponsive to therapy
Coding Notes
Ensure documentation includes bone marrow biopsy results confirming ring sideroblasts.
D46.2 - Refractory anemia with excess blasts
Use when bone marrow biopsy shows 5-19% blasts.
Applicable To
- Refractory anemia with excess blasts (RAEB-1/RAEB-2)
Excludes
- Acute myeloid leukemia (C92.0-)
Clinical Validation Requirements
- Blast percentage (5-9% for RAEB-1; 10-19% for RAEB-2) in bone marrow
Coding Notes
Ensure blast percentage is clearly documented in the medical record.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Myelodysplastic Syndromes to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D46.9.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding guidelines., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure all diagnostic tests are documented., Regularly update the patient's medical record with new findings.
Impact
Reimbursement: Potential for reduced reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines requiring specificity., Data Quality: Decreased data quality and accuracy in patient records.
Mitigation Strategy
Ensure documentation supports the use of specific codes by including subtype details.
Impact
Risk of audits due to use of unspecified codes when specific information is available.
Mitigation Strategy
Ensure documentation supports the use of specific codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Myelodysplastic Syndromes, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Myelodysplastic Syndromes
Use these documentation templates to ensure complete and accurate documentation for Myelodysplastic Syndromes. These templates include all required elements for proper coding and billing.
Hematology Progress Note
Specialty: HematologyRequired Elements
- Assessment and plan for MDS
- Lab results including CBC and bone marrow biopsy
- Treatment plan and follow-up
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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