ICD-10 Code D81.6 | Major histocompatibility complex class I deficiency Symptoms, Diagnosis, Billing

Major histocompatibility complex class I deficiency is a rare immunodeficiency disorder characterized by the absence or dysfunction of class I MHC molecules, leading to impaired cytotoxic T-cell responses. This condition is clinically significant as it predisposes individuals to severe viral infections and certain malignancies. Accurate coding with ICD-10 Code D81.6 is essential for proper diagnosis, documentation, medical billing, and public health reporting.

What is ICD-10 Code D81.6 for Major histocompatibility complex class I deficiency?

ICD-10 Code D81.6 represents Major histocompatibility complex class I deficiency, a genetic disorder that affects the immune system's ability to recognize and respond to infected or malignant cells. This code should be used in clinical documentation and billing when diagnosing patients with this specific immunodeficiency, ensuring accurate representation of the patient's health status and facilitating appropriate treatment and management.

ICD-10 Code D81.6 – Clinical Definition and Explanation of Major histocompatibility complex class I deficiency

Major histocompatibility complex class I deficiency is primarily caused by genetic mutations affecting the expression of MHC class I molecules on cell surfaces. This deficiency leads to a compromised immune response, particularly against viral infections, necessitating prompt medical attention to prevent severe complications.

Key Clinical Features:

• Increased susceptibility to viral infections, particularly from common viruses.
• Potential development of autoimmune disorders due to dysregulated immune responses.
• History of recurrent infections or unusual infections in childhood.
• Possible association with certain malignancies due to impaired immune surveillance.

ICD-10 Code D81.6 for Major histocompatibility complex class I deficiency – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code D81.6 is utilized to document the diagnosis of Major histocompatibility complex class I deficiency, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code D81.6 for Major histocompatibility complex class I deficiency Mean in SOAP Notes?

ICD-10 Code D81.6 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Major histocompatibility complex class I deficiency. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D81.6 – Major histocompatibility complex class I deficiency

Management of Major histocompatibility complex class I deficiency often requires hospitalization due to the risk of severe infections. Treatment focuses on supportive care and preventive measures.

Antibiotic Therapy:

• Not applicable as this condition is not primarily infectious.
• Consider prophylactic antibiotics for patients with recurrent infections.
• Use of antiviral medications may be indicated for specific viral infections.

Supportive Care:

• Regular monitoring for infections and prompt treatment as needed.
• Immunoglobulin replacement therapy may be considered.
• Vaccination against preventable diseases to enhance immunity.

Infection Control:

• Strict hygiene measures to prevent infections.
• Isolation precautions during outbreaks of infectious diseases.
• Education on recognizing early signs of infection.

How to Document Symptoms of Major histocompatibility complex class I deficiency (ICD-10 D81.6) in SOAP Notes

Subjective:

• Patient reports recurrent viral infections, including respiratory illnesses.
• History of unusual infections requiring hospitalization.
• Family history of immunodeficiency disorders.
• Patient expresses concern about frequent illness and fatigue.

Objective:

• Vital signs: stable, with occasional fever during infections.
• Physical examination reveals signs of previous infections.
• Laboratory tests show low levels of cytotoxic T-cells.
• Immunological assessment indicates absent or reduced MHC class I expression.

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SOAP Note Guidelines for Diagnosing Major histocompatibility complex class I deficiency (ICD-10 Code D81.6)

Assessment:

• Diagnosis: Major histocompatibility complex class I deficiency, moderate severity.
• ICD-10 Code: D81.6.
• Triggers: Genetic mutation leading to impaired immune response.
• Contributing factors: History of recurrent infections.

Plan:

• Initiate immunoglobulin replacement therapy as needed.
• Educate patient on infection prevention strategies.
• Schedule regular follow-up appointments for monitoring.
• Consider referral to immunology for specialized management.

Treatment & Plan Section for ICD-10 Code D81.6 – Major histocompatibility complex class I deficiency

• Consider immunoglobulin replacement therapy to boost immune function.
• Implement strict infection control measures and hygiene practices.
• Educate patients on recognizing symptoms of infections early.
• Schedule regular follow-ups to monitor immune status and adjust treatment.

Using ICD-10 Code D81.6 for Major histocompatibility complex class I deficiency in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use D81.6 in appropriate clinical settings, including outpatient and inpatient care.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any associated conditions or complications for comprehensive coding.

Related ICD-10 Codes Often Used with Major histocompatibility complex class I deficiency

• D81.5 – Major histocompatibility complex class II deficiency
• D81.1 – Severe combined immunodeficiency due to adenosine deaminase deficiency
• D81.3 – Other severe combined immunodeficiencies
• D81.9 – Immunodeficiency, unspecified

ICD-10 Code D81.6 in Medical Billing and Insurance for Major histocompatibility complex class I deficiency

ICD-10 Code D81.6 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings and patient history to support the claim.
• Use D81.6 in conjunction with other codes for associated conditions.
• Ensure coding aligns with the patient's clinical presentation and treatment plan.

Common CPT Pairings: