Hodgkin lymphoma, unspecified, intrapelvic lymph nodes is a type of lymphatic cancer characterized by the presence of Reed-Sternberg cells. This condition can arise from genetic mutations or environmental factors. Accurate coding with ICD-10 Code C81.96 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 C81.96 for Hodgkin lymphoma, unspecified, intrapelvic lymph nodes?
ICD-10 Code C81.96 represents Hodgkin lymphoma that is specifically located in the intrapelvic lymph nodes without further specification. This code is utilized when the diagnosis is confirmed but the specific subtype of Hodgkin lymphoma is not identified. It is important for clinical documentation and billing to ensure accurate representation of the patient's condition.
ICD-10 Code C81.96 – Clinical Definition and Explanation of Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
Hodgkin lymphoma, unspecified, intrapelvic lymph nodes is a malignancy of the lymphatic system that can lead to significant morbidity if not treated promptly. The exact cause remains unclear, but it is believed to involve a combination of genetic predisposition and environmental factors. Early detection and treatment are crucial for improving patient outcomes.
Key Clinical Features:
- Presence of painless lymphadenopathy in the pelvic region.
- B symptoms such as fever, night sweats, and weight loss.
- Potential for splenomegaly or hepatomegaly.
- Diagnosis confirmed through biopsy showing Reed-Sternberg cells.
ICD-10 Code C81.96 for Hodgkin lymphoma, unspecified, intrapelvic lymph nodes – SOAP Notes & Clinical Use
ICD-10 Code C81.96 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation that supports clinical decision-making and billing processes.
What Does ICD-10 Code C81.96 for Hodgkin lymphoma, unspecified, intrapelvic lymph nodes Mean in SOAP Notes?
In SOAP notes, ICD-10 Code C81.96 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Hodgkin lymphoma affecting the intrapelvic lymph nodes. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code C81.96 – Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
Prompt treatment of Hodgkin lymphoma is critical to prevent disease progression. Hospitalization may be required for severe cases, and treatment typically involves chemotherapy and/or radiation therapy.
Antibiotic Therapy:
- Not applicable as Hodgkin lymphoma is not an infectious disease.
Supportive Care:
- Pain management with analgesics.
- Nutritional support to maintain strength.
- Psychosocial support for emotional well-being.
Infection Control:
- Standard precautions to prevent infections during treatment.
- Monitoring for febrile neutropenia in patients undergoing chemotherapy.
How to Document Symptoms of Hodgkin lymphoma, unspecified, intrapelvic lymph nodes (ICD-10 C81.96) in SOAP Notes
Subjective:
- Patient reports painless swelling in the pelvic area.
- Experiencing night sweats and unintentional weight loss.
- History of fatigue and generalized malaise.
- No significant past medical history noted.
Objective:
- Physical examination reveals enlarged lymph nodes in the pelvic region.
- Vital signs: temperature 100.5°F, heart rate 85 bpm.
- Laboratory tests show elevated lactate dehydrogenase (LDH).
- Biopsy results confirm the presence of Reed-Sternberg cells.
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SOAP Note Guidelines for Diagnosing Hodgkin lymphoma, unspecified, intrapelvic lymph nodes (ICD-10 Code C81.96)
Assessment:
- Diagnosis: Hodgkin lymphoma, unspecified, intrapelvic lymph nodes, Stage II.
- ICD-10 Code: C81.96.
- Contributing factors: Possible genetic predisposition.
- Patient presents with B symptoms indicating systemic involvement.
Plan:
- Initiate chemotherapy regimen (ABVD protocol).
- Schedule follow-up appointments for monitoring treatment response.
- Educate patient on potential side effects and supportive care measures.
- Consider referral to oncology for specialized management.
Treatment & Plan Section for ICD-10 Code C81.96 – Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
- First-line pharmacologic treatment includes combination chemotherapy (e.g., ABVD).
- Non-pharmacologic strategies include nutritional counseling and psychosocial support.
- Monitoring practices involve regular imaging studies and laboratory tests to assess treatment efficacy.
- Follow-up appointments should be scheduled every 3 months for the first year post-treatment.
Using ICD-10 Code C81.96 for Hodgkin lymphoma, unspecified, intrapelvic lymph nodes in Billing & SOAP Note Compliance
- Select appropriate ICD-10 codes based on clinical findings and documentation.
- Ensure Subjective (S) and Objective (O) sections reflect the patient's symptoms and clinical status.
- Treatment plans must align with clinical guidelines to support justified billing.
- CPT codes should be accurately paired with ICD-10 Code C81.96 for comprehensive billing.
Related ICD-10 Codes Often Used with Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
- C81.90 – Hodgkin lymphoma, unspecified, lymph nodes of multiple sites
- C81.91 – Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
- C81.92 – Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb
- C81.93 – Hodgkin lymphoma, unspecified, lymph nodes of mediastinum
ICD-10 Code C81.96 in Medical Billing and Insurance for Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
ICD-10 Code C81.96 is crucial for accurate billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant patient history and clinical findings to support the diagnosis.
- Use C81.96 in conjunction with other codes as necessary to capture the full clinical picture.
- Ensure that all documentation aligns with payer requirements for reimbursement.
- Include detailed treatment plans and follow-up care in the patient's record.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 96413 | Chemotherapy administration, intravenous, push technique. |
| 36415 | Collection of venous blood by venipuncture. |
| 99214 | Established patient office visit, moderate complexity. |
| 85025 | Complete blood count with automated differential. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code C81.96 for Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
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 of affected lymph nodes to identify Reed-Sternberg cells.
What treatments are available for Hodgkin lymphoma?
Treatment options include chemotherapy, radiation therapy, and in some cases, stem cell transplantation. The specific regimen depends on the stage and subtype 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.
