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v1.0.0
ICD-10 Guide
ICD-10 CodesD89.831

D89.831

Billable

Cytokine release syndrome, grade 1

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 D89.831 is a billable code used to indicate a diagnosis of cytokine release syndrome, grade 1.

Key Diagnostic Point:

Cytokine release syndrome (CRS) is a systemic inflammatory response that can occur following certain therapies, particularly immunotherapies such as CAR T-cell therapy or monoclonal antibodies. Grade 1 CRS is characterized by mild symptoms, which may include fever, fatigue, and mild hypotension, but does not require intensive medical intervention. The pathophysiology involves the activation of immune cells leading to the release of pro-inflammatory cytokines, which can cause a cascade of inflammatory responses. In grade 1 CRS, the symptoms are generally self-limiting and resolve with supportive care. Monitoring is essential to ensure that symptoms do not escalate to higher grades of CRS, which can lead to more severe complications such as organ dysfunction. Accurate coding of CRS is crucial for appropriate treatment documentation and reimbursement, as well as for tracking the incidence of this condition in patients undergoing specific therapies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of immunotherapy-related adverse effects
  • Differentiation from other inflammatory conditions
  • Need for precise grading of CRS severity
  • Documentation of clinical symptoms and treatment response

Audit Risk Factors

  • Inadequate documentation of symptom severity
  • Failure to document the treatment context (e.g., immunotherapy)
  • Misclassification of CRS grade
  • Lack of follow-up documentation on symptom resolution

Specialty Focus

Medical Specialties

Hematology/Oncology

Documentation Requirements

Detailed documentation of treatment history, symptom onset, and grading of CRS.

Common Clinical Scenarios

Patients receiving CAR T-cell therapy experiencing mild fever and fatigue.

Billing Considerations

Ensure that the immunotherapy type is clearly documented to support the diagnosis of CRS.

Immunology

Documentation Requirements

Comprehensive records of immune response assessments and cytokine levels.

Common Clinical Scenarios

Patients with autoimmune disorders receiving monoclonal antibodies showing mild CRS symptoms.

Billing Considerations

Document any pre-existing conditions that may influence CRS severity.

Coding Guidelines

Inclusion Criteria

Use D89.831 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the patient's treatment history and symptomatology
  • Include specific details about the immunotherapy used and the patient's response to treatment

Exclusion Criteria

Do NOT use D89.831 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

96413CPT Code

Chemotherapy administration, intravenous, push technique

Clinical Scenario

Used when administering immunotherapy that may lead to CRS.

Documentation Requirements

Document the type of chemotherapy and any observed side effects.

Specialty Considerations

Oncology specialists should ensure that CRS symptoms are documented during treatment.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like cytokine release syndrome, improving the ability to track and manage these adverse effects in patients receiving immunotherapy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like cytokine release syndrome, improving the ability to track and manage these adverse effects in patients receiving immunotherapy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like cytokine release syndrome, improving the ability to track and manage these adverse effects in patients receiving immunotherapy.

Resources

Clinical References

  • •
    Cytokine Release Syndrome: A Guide for Clinicians

Coding & Billing References

  • •
    Cytokine Release Syndrome: A Guide for Clinicians

Frequently Asked Questions

What are the symptoms of grade 1 cytokine release syndrome?

Grade 1 CRS symptoms typically include mild fever, fatigue, and mild hypotension. These symptoms are generally self-limiting and do not require intensive medical intervention.

How is cytokine release syndrome diagnosed?

Diagnosis is based on clinical symptoms, treatment history, and the grading of symptoms according to established criteria. Documentation of the patient's immunotherapy treatment is essential.