Hodgkin lymphoma, unspecified, unspecified site is a type of lymphatic cancer characterized by the presence of Reed-Sternberg cells. The exact cause remains unclear, but it is believed to involve genetic mutations and environmental factors. Accurate coding with ICD-10 Code C81.90 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 C81.90 for Hodgkin lymphoma, unspecified, unspecified site?
ICD-10 Code C81.90 represents Hodgkin lymphoma that is unspecified and located at an unspecified site. This code is used when the specific type or location of Hodgkin lymphoma is not documented. It is crucial for clinical documentation and billing to ensure accurate representation of the patient's condition, facilitating appropriate treatment and resource allocation.
ICD-10 Code C81.90 – Clinical Definition and Explanation of Hodgkin lymphoma, unspecified, unspecified site
Hodgkin lymphoma, unspecified, unspecified site is a malignancy of the lymphatic system that can progress if left untreated. It requires prompt medical attention due to its potential to spread to other areas of the body. Early diagnosis and treatment are critical for improving patient outcomes.
Key Clinical Features:
- Presence of painless lymphadenopathy, often in the neck, axilla, or groin.
- Symptoms may include fever, night sweats, and unexplained weight loss.
- Reed-Sternberg cells are a hallmark of the disease, identifiable through biopsy.
- Can occur in any age group, but most commonly diagnosed in young adults.
ICD-10 Code C81.90 for Hodgkin lymphoma, unspecified, unspecified site – SOAP Notes & Clinical Use
ICD-10 Code C81.90 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It plays a vital role in both acute and chronic care settings, ensuring comprehensive documentation that supports clinical decision-making and billing processes.
What Does ICD-10 Code C81.90 for Hodgkin lymphoma, unspecified, unspecified site Mean in SOAP Notes?
In SOAP notes, ICD-10 Code C81.90 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Hodgkin lymphoma. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code C81.90 – Hodgkin lymphoma, unspecified, unspecified site
Hodgkin lymphoma requires urgent medical intervention, often necessitating hospitalization for treatment. Standard approaches include chemotherapy and radiation therapy tailored to the patient's specific needs.
Antibiotic Therapy:
- Not applicable as Hodgkin lymphoma is not an infectious disease.
Supportive Care:
- Management of symptoms such as pain and nausea.
- Nutritional support to maintain strength during treatment.
- Psychosocial support for emotional well-being.
Infection Control:
- Standard precautions to prevent infections during treatment.
- Monitoring for signs of infection due to immunosuppression.
How to Document Symptoms of Hodgkin lymphoma, unspecified, unspecified site (ICD-10 C81.90) in SOAP Notes
Subjective:
- Patient reports painless swelling in the neck.
- Experiencing night sweats and fatigue.
- Unintentional weight loss of 10 pounds over the last month.
- No history of recent infections or travel.
Objective:
- Physical examination reveals enlarged cervical lymph nodes.
- Vital signs: BP 120/80, HR 78, Temp 99.5°F.
- CBC shows mild anemia.
- Biopsy results indicate presence of Reed-Sternberg cells.
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 Hodgkin lymphoma, unspecified, unspecified site (ICD-10 Code C81.90)
Assessment:
- Diagnosis: Hodgkin lymphoma, unspecified, unspecified site (ICD-10 Code C81.90).
- Severity: Moderate, based on lymph node involvement.
- Contributing factors: Possible genetic predisposition.
- No known allergies reported.
Plan:
- Initiate chemotherapy regimen as per oncology guidelines.
- Schedule follow-up appointments for monitoring treatment response.
- Educate patient on potential side effects and symptom management.
- Refer to support services for psychological support.
Treatment & Plan Section for ICD-10 Code C81.90 – Hodgkin lymphoma, unspecified, unspecified site
- First-line treatment typically includes ABVD chemotherapy regimen.
- Consider radiation therapy for localized disease after chemotherapy.
- Regular monitoring through imaging studies to assess treatment response.
- Patient education on lifestyle modifications to support overall health.
Using ICD-10 Code C81.90 for Hodgkin lymphoma, unspecified, unspecified site in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
- Use C81.90 when specific type or site of Hodgkin lymphoma is not documented.
- Align treatment plans with clinical guidelines to support justified billing.
- Include relevant patient history and examination findings to substantiate the diagnosis.
Related ICD-10 Codes Often Used with Hodgkin lymphoma, unspecified, unspecified site
- C81.91 – Hodgkin lymphoma, unspecified, cervical lymph nodes
- C81.92 – Hodgkin lymphoma, unspecified, mediastinal lymph nodes
- C81.93 – Hodgkin lymphoma, unspecified, axillary lymph nodes
- C81.94 – Hodgkin lymphoma, unspecified, inguinal lymph nodes
ICD-10 Code C81.90 in Medical Billing and Insurance for Hodgkin lymphoma, unspecified, unspecified site
ICD-10 Code C81.90 is critical in medical billing, particularly in hospital and emergency room settings, where accurate coding is essential for reimbursement.
Billing Notes:
- Document all relevant patient history and clinical findings to support the ICD-10 claim.
- Use C81.90 in cases where the specific type or site of Hodgkin lymphoma is not specified.
- Ensure that treatment plans are clearly outlined in the medical record to justify billing.
- Review coding guidelines regularly to stay compliant with billing practices.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 96413 | Chemotherapy administration, intravenous, push, single or initial substance. |
| 36415 | Collection of venous blood by venipuncture. |
| 77014 | Radiologic guidance for needle placement. |
| 99214 | Established patient office visit, moderate complexity. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code C81.90 for Hodgkin lymphoma, unspecified, unspecified site
What are the common symptoms of Hodgkin lymphoma?
Common symptoms include painless swelling of lymph nodes, fever, night sweats, and unexplained weight loss. Patients may also experience fatigue and itching.
How is Hodgkin lymphoma diagnosed?
Diagnosis typically involves a physical examination, imaging studies, and a biopsy to identify Reed-Sternberg cells. Blood tests may also be conducted to assess overall health.
What treatments are available for Hodgkin lymphoma?
Treatment options include chemotherapy, radiation therapy, and in some cases, stem cell transplantation. The specific approach depends on the stage and location of the disease.
Is Hodgkin lymphoma contagious?
No, Hodgkin lymphoma is not contagious. It is a type of cancer that arises from the lymphatic system and cannot be transmitted from person to person.
