Find comprehensive information on Immune Thrombocytopenia (ITP) diagnosis, including clinical documentation requirements, ICD-10 codes (D69.3), medical coding guidelines, and healthcare best practices. Learn about ITP symptoms, treatment options, and platelet count implications for accurate medical record keeping and billing. This resource provides essential information for healthcare professionals, coders, and clinicians involved in ITP patient care and documentation.
Also known as
Immune thrombocytopenic purpura
Low platelet count caused by immune system destroying platelets.
Other thrombocytopenia
Low platelet count not otherwise specified, may include immune causes.
Thrombocytopenia unspecified
Low platelet count with no specific cause identified.
Other specified platelet disorders
Includes other rare platelet disorders that may overlap with ITP.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the thrombocytopenia immune-mediated?
Yes
Is it drug-induced?
No
Do NOT code as immune thrombocytopenia. Evaluate for other causes.
When to use each related code
| Description |
|---|
| Low platelets, often idiopathic |
| Low platelets due to heparin |
| Low platelets, microangiopathy |
Coding for ITP (D69.3) requires distinguishing it from other thrombocytopenias. Misdiagnosis or unspecified documentation leads to inaccurate coding and potential DRG misclassification.
Severity level (e.g., acute vs. chronic, primary vs. secondary) impacts coding and reimbursement. Insufficient documentation can lead to downcoding and lost revenue.
If ITP is drug-induced or secondary to another condition, both diagnoses must be coded. Missing the underlying cause affects data accuracy and quality reporting.
Patient presents with signs and symptoms suggestive of immune thrombocytopenia (ITP). Key findings include petechiae, purpura, ecchymosis, and a documented low platelet count. The patient reports no recent trauma or history of other bleeding disorders. Complete blood count (CBC) reveals thrombocytopenia, with platelets less than [insert platelet value] x 10^9L. Peripheral blood smear demonstrates isolated thrombocytopenia without other abnormalities, ruling out pseudothrombocytopenia. The patient denies any known family history of ITP or autoimmune disorders. Symptoms onset was [insert timeframe]. Based on the clinical presentation, laboratory findings, and absence of alternative explanations, a diagnosis of primary immune thrombocytopenia is made. Differential diagnosis considered included drug-induced thrombocytopenia, thrombotic thrombocytopenic purpura (TTP), and heparin-induced thrombocytopenia (HIT), which were ruled out based on medication history, normal coagulation studies (PT, aPTT, INR), and lack of schistocytes on peripheral smear. Treatment options including corticosteroids, intravenous immunoglobulin (IVIG), and thrombopoietin receptor agonists (TPO-RAs) were discussed with the patient. The initial treatment plan is [insert treatment plan, e.g., prednisone 1 mgkgday]. Patient education was provided regarding bleeding precautions, avoidance of NSAIDs and aspirin, and follow-up appointments for monitoring platelet counts and treatment response. ICD-10 code D69.3 (Immune thrombocytopenic purpura) is assigned. The patient will be closely monitored for complications such as severe bleeding or refractory thrombocytopenia. Further investigations may be considered if the patient fails to respond to initial therapy.