ICD-10 Code D89.831 | Cytokine release syndrome, grade 1 Symptoms, Diagnosis, Billing

Cytokine release syndrome, grade 1, is a mild inflammatory response characterized by the release of cytokines into the bloodstream, often triggered by certain therapies such as immunotherapy or infections. This condition is clinically significant as it can progress to more severe forms if not monitored. The ICD-10 Code D89.831 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and resource allocation.

What is ICD-10 Code D89.831 for Cytokine release syndrome, grade 1?

ICD-10 Code D89.831 represents Cytokine release syndrome, grade 1, which is a mild form of cytokine release syndrome typically associated with certain medical treatments or infections. This code should be used in clinical documentation and billing when a patient exhibits mild symptoms of cytokine release syndrome, allowing for proper tracking and management of the condition.

ICD-10 Code D89.831 – Clinical Definition and Explanation of Cytokine release syndrome, grade 1

Cytokine release syndrome, grade 1, is primarily caused by the activation of the immune system, often in response to therapies such as monoclonal antibodies or CAR T-cell therapy. It can progress if not adequately addressed, necessitating medical attention to prevent complications.

Key Clinical Features:

• Mild fever and chills
• Fatigue and malaise
• Nausea and vomiting
• Mild hypotension

ICD-10 Code D89.831 for Cytokine release syndrome, grade 1 – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code D89.831 is utilized to document the presence of mild cytokine release syndrome. It aids in capturing symptoms, assessments, and treatment plans, relevant in both acute and chronic care settings.

What Does ICD-10 Code D89.831 for Cytokine release syndrome, grade 1 Mean in SOAP Notes?

ICD-10 Code D89.831 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of mild cytokine release syndrome, ensuring continuity of care, supporting billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D89.831 – Cytokine release syndrome, grade 1

Cytokine release syndrome, grade 1, may require hospitalization for monitoring and treatment. Management focuses on supportive care and addressing underlying causes.

Antibiotic Therapy:

• Not typically indicated unless an infection is present.
• Consideration for empiric therapy based on clinical judgment.

Supportive Care:

• Hydration and electrolyte management.
• Antipyretics for fever control.
• Monitoring vital signs closely.

Infection Control:

• Standard precautions to prevent infection spread.
• Isolation if associated with infectious etiology.

How to Document Symptoms of Cytokine release syndrome, grade 1 (ICD-10 D89.831) in SOAP Notes

Subjective:

• Patient reports mild fever and chills.
• Complains of fatigue and general malaise.
• Nausea experienced intermittently.
• No significant past medical history of similar episodes.

Objective:

• Vital signs: Temperature 100.5°F, BP 90/60 mmHg.
• Physical exam shows mild dehydration.
• Laboratory tests indicate elevated inflammatory markers.
• No signs of acute respiratory distress.

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SOAP Note Guidelines for Diagnosing Cytokine release syndrome, grade 1 (ICD-10 Code D89.831)

Assessment:

• Diagnosis: Cytokine release syndrome, grade 1 (ICD-10 D89.831).
• Severity: Mild, with no immediate life-threatening complications.
• Triggers: Recent immunotherapy treatment.
• Monitoring for progression to higher-grade syndrome.

Plan:

• Administer IV fluids for hydration.
• Provide antipyretics as needed for fever.
• Monitor vital signs every 4 hours.
• Schedule follow-up in 24 hours or sooner if symptoms worsen.

Treatment & Plan Section for ICD-10 Code D89.831 – Cytokine release syndrome, grade 1

• First-line treatment includes hydration and antipyretics.
• Non-pharmacologic strategies involve patient education on symptom management.
• Monitoring includes regular assessment of vital signs and laboratory tests.
• Follow-up appointments to reassess symptoms and treatment efficacy.

Using ICD-10 Code D89.831 for Cytokine release syndrome, grade 1 in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings.
• Document symptoms clearly under Subjective (S) and Objective (O) sections.
• Ensure treatment plans align with clinical guidelines for justified billing.
• Include relevant CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Cytokine release syndrome, grade 1

• D89.832 – Cytokine release syndrome, grade 2
• D89.833 – Cytokine release syndrome, grade 3
• D89.839 – Cytokine release syndrome, unspecified grade

ICD-10 Code D89.831 in Medical Billing and Insurance for Cytokine release syndrome, grade 1

ICD-10 Code D89.831 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement and compliance.

Billing Notes:

• Document all relevant symptoms and treatments to support the claim.
• Use the code in settings where cytokine release syndrome is diagnosed.
• Ensure that the documentation reflects the severity and treatment provided.
• Include any comorbid conditions that may affect billing.

Common CPT Pairings: