ICD-10 Code D81.4 | Nezelof's syndrome Symptoms, Diagnosis, Billing

Nezelof's syndrome is a rare immunodeficiency disorder characterized by a specific defect in T-cell development, leading to severe combined immunodeficiency. This condition is clinically significant as it predisposes individuals to recurrent infections and autoimmune disorders. Accurate coding with ICD-10 Code D81.4 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 D81.4 for Nezelof's syndrome?

ICD-10 Code D81.4 represents Nezelof's syndrome, a genetic disorder resulting in T-cell immunodeficiency. This code should be used in clinical documentation and billing when diagnosing patients with this condition, particularly when they present with recurrent infections or other complications related to immune dysfunction.

ICD-10 Code D81.4 – Clinical Definition and Explanation of Nezelof's syndrome

Nezelof's syndrome is caused by a genetic defect affecting T-cell maturation, leading to a compromised immune system. The condition requires prompt medical attention due to the risk of severe infections and complications. Early diagnosis and management are crucial for improving patient outcomes.

Key Clinical Features:

• Severe recurrent infections, particularly viral and fungal.
• Failure to thrive in infants and young children.
• Autoimmune manifestations, such as autoimmune hemolytic anemia.
• Lymphopenia and abnormal T-cell counts on laboratory tests.

ICD-10 Code D81.4 for Nezelof's syndrome – SOAP Notes & Clinical Use

ICD-10 Code D81.4 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 of the patient's immunodeficiency status.

What Does ICD-10 Code D81.4 for Nezelof's syndrome Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D81.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Nezelof's syndrome. This coding ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D81.4 – Nezelof's syndrome

Hospitalization may be necessary for patients with Nezelof's syndrome due to the risk of severe infections. Treatment focuses on managing symptoms and preventing complications.

Antibiotic Therapy:

• First-line: Intravenous immunoglobulin (IVIG) therapy.
• Alternative: Prophylactic antibiotics such as trimethoprim-sulfamethoxazole.
• Duration: Continuous IVIG therapy as needed based on clinical response.

Supportive Care:

• Regular monitoring for infections and immune function.
• Nutritional support to address failure to thrive.
• Vaccination against preventable diseases, considering immunization guidelines.

Infection Control:

• Strict hand hygiene practices.
• Isolation precautions during outbreaks of infectious diseases.
• Education on recognizing early signs of infection.

How to Document Symptoms of Nezelof's syndrome (ICD-10 D81.4) in SOAP Notes

Subjective:

• Patient reports recurrent respiratory infections.
• History of failure to thrive since infancy.
• Family history of immunodeficiency disorders.
• Patient expresses concern about frequent illnesses.

Objective:

• Vital signs: stable but with low-grade fever.
• Laboratory findings: lymphopenia and low T-cell counts.
• Physical exam: signs of previous infections, such as oral thrush.
• Imaging: chest X-ray shows signs of pneumonia.

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SOAP Note Guidelines for Diagnosing Nezelof's syndrome (ICD-10 Code D81.4)

Assessment:

• Diagnosis: Nezelof's syndrome (ICD-10 D81.4), severe combined immunodeficiency.
• Severity: Moderate to severe based on clinical presentation.
• Triggers: Recurrent infections and autoimmune symptoms.
• Consideration of genetic testing for confirmation.

Plan:

• Initiate IVIG therapy and monitor response.
• Educate family on infection prevention strategies.
• Schedule regular follow-up appointments for monitoring.
• Consider referral to immunology for further management.

Treatment & Plan Section for ICD-10 Code D81.4 – Nezelof's syndrome

• Administer IVIG therapy to boost immune function.
• Implement prophylactic antibiotics to prevent infections.
• Provide nutritional support and monitor growth.
• Educate on infection control measures and early symptom recognition.

Using ICD-10 Code D81.4 for Nezelof's syndrome in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use D81.4 in appropriate clinical settings, including inpatient and outpatient care.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes that correspond to services provided.

Related ICD-10 Codes Often Used with Nezelof's syndrome

• D81.0 – Severe combined immunodeficiency due to adenosine deaminase deficiency
• D81.1 – Severe combined immunodeficiency due to other specified genetic defects
• D81.3 – Severe combined immunodeficiency due to X-linked agammaglobulinemia
• D80.9 – Immunodeficiency, unspecified

ICD-10 Code D81.4 in Medical Billing and Insurance for Nezelof's syndrome

ICD-10 Code D81.4 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant clinical findings to support the use of D81.4.
• Use this code in conjunction with other relevant codes for comprehensive billing.
• Ensure that the patient's medical history reflects the severity of the condition.
• Include detailed notes on treatment plans and patient education.

Common CPT Pairings: