Combined immunodeficiency, unspecified
ICD-10 D81.9 is a billable code used to indicate a diagnosis of combined immunodeficiency, unspecified.
Combined immunodeficiency (CID) refers to a group of disorders characterized by the dysfunction of both humoral and cell-mediated immunity. This condition results in an increased susceptibility to infections, autoimmune diseases, and malignancies. The unspecified designation indicates that the specific type of combined immunodeficiency has not been determined. Patients may present with recurrent infections, failure to thrive, and other systemic symptoms. The underlying pathophysiology often involves genetic mutations affecting lymphocyte development and function, leading to inadequate immune responses. Diagnosis typically involves immunological testing, including lymphocyte counts and functional assays, to assess the integrity of both T and B cell functions. Management may include immunoglobulin replacement therapy, prophylactic antibiotics, and in some cases, hematopoietic stem cell transplantation. Due to the complexity of the immune system, the clinical presentation can vary widely, necessitating a thorough evaluation to guide treatment and monitor for complications.
Detailed immunological assessment results, including lymphocyte counts and functional assays.
Patients presenting with recurrent infections, failure to thrive, or autoimmune manifestations.
Ensure that all immunological evaluations are documented to support the diagnosis.
Growth charts, vaccination history, and detailed accounts of recurrent infections.
Infants or children with failure to thrive and frequent infections.
Documenting the timeline of infections and any interventions taken is crucial.
Used for obtaining blood samples for immunological testing.
Document the reason for blood draw and any relevant patient history.
Ensure that the specialty performing the test is noted.
Document all clinical findings, laboratory results, and any treatments provided. Ensure that the rationale for the diagnosis is clear and supported by evidence.
