What should be coded when both sickle cell disease and trait are documented in the patient's record?

When both sickle cell disease and sickle cell trait are documented in a patient's record, the coding practice is to focus on sickle cell disease, as this condition represents a more severe manifestation of the genetic disorder. In ICD-10-CM coding, it is essential to prioritize the more serious condition when multiple related diagnoses are present. Sickle cell disease is a significant and chronic condition with implications for health management, treatment, and patient care that extends beyond what is indicated by having sickle cell trait alone.

While sickle cell trait may be recorded in the patient's history and has its implications, it does not carry the same clinical significance as sickle cell disease in terms of coding. The ICD-10-CM guidelines instruct coders to assign the code that reflects the more serious condition, which in this case is sickle cell disease. Therefore, while both conditions are genetic, the focus should be on the condition that requires more detailed monitoring and management, hence the coding should reflect sickle cell disease as the priority diagnosis.