2025 ICD-10-CM code D86.9
(Active) Effective Date: N/A Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism - Certain disorders involving the immune mechanism (D80-D89) Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) Feed
Sarcoidosis, unspecified.
Medical necessity for diagnostic testing and treatment should be documented based on the patient's clinical presentation and the severity of the disease.
Clinicians should document the specific organ(s) involved in sarcoidosis whenever possible.Diagnosis is based on a combination of patient history, physical exam, imaging studies (such as chest x-ray and CT scan), and biopsy, if necessary. Laboratory tests may include ACE levels, calcium levels, and other inflammatory markers. Treatment depends on the severity and location of the disease and may include corticosteroids, methotrexate, or other immunosuppressants.
- Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
- Certaindisorders involving the immune mechanism (D80-D89) Includes: defects in the complement systemimmunodeficiency disorders, except human immunodeficiency virus [HIV] diseasesarcoidosis Excludes1: autoimmune disease (systemic) NOS (M35.9)functional disorders of polymorphonuclear neutrophils (D71)human immunodeficiency virus [HIV] disease (B20)
In simple words: Sarcoidosis is a condition where small lumps of inflamed cells, called granulomas, form in different organs. It most often affects the lungs, lymph nodes, and skin. This code is used when the doctor doesn't specify which part of the body is affected by sarcoidosis.
Sarcoidosis is a systemic inflammatory disease of unknown cause characterized by the formation of non-necrotizing granulomas.It can affect any organ, but most commonly involves the lungs, lymph nodes, and skin.This code is used when the specific site of sarcoidosis is not documented.
Example 1: A patient presents with fatigue, cough, and shortness of breath.Chest x-ray reveals bilateral hilar lymphadenopathy.A biopsy confirms the diagnosis of sarcoidosis, but the physician does not document the specific site of involvement, therefore D86.9 is used., A patient with known pulmonary sarcoidosis develops new skin lesions. The lesions are biopsied and confirm sarcoidosis. As the documentation does not specify that this is cutaneous sarcoidosis, D86.9 is used., A patient is found to have granulomas in the liver on an abdominal CT scan. Further investigation and biopsy confirm sarcoidosis. Since documentation does not mention the site being liver, code D86.9 is reported.
Documentation should include signs, symptoms, examination findings, imaging results, biopsy results (if performed), and any other relevant diagnostic testing.It is crucial to document the affected organ(s) to support the use of a more specific sarcoidosis code if possible.
** Sarcoidosis can mimic other conditions, and a thorough differential diagnosis is essential. If the documentation clearly indicates a particular organ system is affected, a more specific code should be used. If the documentation states "sarcoidosis" without specifying the affected organ/site, use D86.9.
- Payment Status: Active
- Specialties:Pulmonology, Rheumatology, Dermatology, Internal Medicine, Ophthalmology, Cardiology, and others depending on the site of involvement.
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, and other places of service depending on the clinical scenario.