Elevated levels of cytokines in an overactive immune system can cause harmful levels of inflammation throughout the body and disrupt organ functioning.
Q: We have a patient admitted for COVID-19 who is now showing signs of cytokine release syndrome (CRS). Can you give our team more information on symptoms or clinical indicators for CRS as well as any ICD-10-CM coding advice?
A: CRS is a systemic inflammatory response that can be triggered by infections and certain drugs. CRS is often reported in admitted patients suffering from viral respiratory infections such as COVID-19 or influenza. It is also a common adverse effect of chimeric antigen receptor T-cell therapy—immunotherapy that uses specially altered T-cells to fight cancer.
Cytokines are small proteins that facilitate communication between body cells. When the immune system detects a threat, immune cells release cytokines to coordinate the body’s response. Elevated levels of cytokines in an overactive immune system can cause harmful levels of inflammation throughout the body and disrupt organ functioning.
Symptoms of CRS range from mild to severe and may include:
- Elevated/irregular heartrate
- Organ failure
- Persistent coughing
- Precipitous drop in blood pressure
- Reduced lung functioning
- Shortness of breath
A consensus grading system for CRS has been developed by experts in the field, and it may help guide your interventions for patients receiving immunological therapies. The American Society for Transplantation and Cellular Therapy consensus for grading CRS is as follows:
- Grade 1: Patient has a fever, defined as a temperature of 38.0°C or higher
- Grade 2: Patient has a fever, hypotension that doesn’t require vasopressors, and/or hypoxia that requires oxygen delivered by low-flow nasal cannula (less than or equal to 6 L/min) or blow-by
- Grade 3: Patient has a fever, hypotension requiring one vasopressor (with or without vasopressin), and/or hypoxia (not attributable to any other cause) that requires high-flow nasal cannula (greater than 6 L/min), facemask, non-rebreather mask, or venturi mask
- Grade 4: Patient has a fever, hypotension requiring multiple vasopressors (excluding vasopressin), and/or hypoxia (not attributable to any other cause) requiring positive-pressure ventilation
- Grade 5: Death due to CRS when there is no other principal factor leading to death
The 2021 ICD-10-CM update introduced the following new codes for different grades of CRS:
- D89.831, CRS; grade 1
- D89.832, …; grade 2
- D89.833, …; grade 3
- D89.834, …; grade 4
- D89.935, …; grade 5
- D89.839, …; grade unspecified
The ICD-10-CM codes for grades 3-5 are complication or comorbidity conditions.