Shigellosis, unspecified is an infectious disease caused by Shigella bacteria, leading to gastrointestinal symptoms such as diarrhea, fever, and abdominal cramps. Accurate coding with ICD-10 Code A03.9 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring effective management and tracking of this communicable disease.
What is ICD-10 Code A03.9 for Shigellosis, unspecified?
ICD-10 Code A03.9 represents Shigellosis, unspecified, a bacterial infection characterized by diarrhea, often with blood or mucus, caused by Shigella species. This code is used when the specific type of Shigella is not identified. It is essential for clinical documentation and billing when diagnosing patients with gastrointestinal symptoms consistent with shigellosis.
ICD-10 Code A03.9 – Clinical Definition and Explanation of Shigellosis, unspecified
Shigellosis is primarily caused by the ingestion of contaminated food or water, leading to inflammation of the intestinal lining. The condition can progress rapidly, resulting in severe dehydration and requires prompt medical attention.
Key Clinical Features:
- Acute diarrhea, often bloody or mucoid
- Abdominal pain and cramping
- Fever and malaise
- Nausea and vomiting
- Dehydration risk, especially in young children and the elderly
ICD-10 Code A03.9 for Shigellosis, unspecified – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code A03.9 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to shigellosis. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code A03.9 for Shigellosis, unspecified Mean in SOAP Notes?
ICD-10 Code A03.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of shigellosis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code A03.9 – Shigellosis, unspecified
Shigellosis requires prompt treatment to prevent complications, particularly dehydration. Antibiotic therapy is often indicated, along with supportive care.
Antibiotic Therapy:
- Ciprofloxacin 500 mg orally twice daily for 3 days (first-line)
- Azithromycin 1 g orally once (alternative for resistant strains)
- Ceftriaxone 1 g IV daily for severe cases
Supportive Care:
- Oral rehydration solutions to prevent dehydration
- Intravenous fluids for severe dehydration
- Antipyretics for fever management
Infection Control:
- Strict hand hygiene practices
- Isolation of infected individuals during outbreaks
- Education on safe food and water practices
How to Document Symptoms of Shigellosis, unspecified (ICD-10 A03.9) in SOAP Notes
Subjective:
- Patient reports diarrhea with blood and mucus for 2 days
- Complains of severe abdominal cramps and fever
- History of recent travel to an area with poor sanitation
- Denies recent antibiotic use
Objective:
- Vital signs: Temperature 101°F, heart rate 110 bpm
- Abdominal exam: Tenderness in the lower quadrants
- Stool sample: Positive for Shigella species
- Signs of dehydration: Dry mucous membranes
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SOAP Note Guidelines for Diagnosing Shigellosis, unspecified (ICD-10 Code A03.9)
Assessment:
- Diagnosis: Shigellosis, unspecified, moderate severity
- ICD-10 Code: A03.9
- Contributing factors: Recent travel to endemic area, possible foodborne transmission
- Risk of dehydration noted
Plan:
- Initiate antibiotic therapy with ciprofloxacin
- Start oral rehydration therapy
- Educate patient on hygiene and food safety
- Schedule follow-up in 48 hours to reassess hydration status
Treatment & Plan Section for ICD-10 Code A03.9 – Shigellosis, unspecified
- First-line antibiotic treatment with ciprofloxacin or azithromycin
- Encourage increased fluid intake and monitor hydration status
- Educate on hygiene practices to prevent transmission
- Follow-up appointments to monitor recovery and symptom resolution
Using ICD-10 Code A03.9 for Shigellosis, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in SOAP notes
- Use A03.9 for unspecified cases when specific Shigella type is not identified
- Align treatment plans with clinical guidelines to support billing
- Include relevant CPT codes for laboratory tests and consultations
Related ICD-10 Codes Often Used with Shigellosis, unspecified
- A03.0 – Shigellosis due to Shigella dysenteriae
- A03.1 – Shigellosis due to Shigella flexneri
- A03.2 – Shigellosis due to Shigella boydii
- A03.3 – Shigellosis due to Shigella sonnei
ICD-10 Code A03.9 in Medical Billing and Insurance for Shigellosis, unspecified
ICD-10 Code A03.9 is critical for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant clinical findings and patient history to support the diagnosis
- Use A03.9 in cases where the specific Shigella type is not identified
- Ensure compliance with coding guidelines to avoid claim denials
- Include detailed notes on treatment and patient education in the medical record
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 87449 | Infectious agent detection by nucleic acid (e.g., PCR) for Shigella |
| 99213 | Established patient office visit, level 3 |
| 96372 | Therapeutic, prophylactic, or diagnostic injection |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A03.9 for Shigellosis, unspecified
What are the common symptoms of shigellosis?
Common symptoms of shigellosis include diarrhea (often bloody), abdominal cramps, fever, and nausea. Symptoms typically appear 1-3 days after exposure to the bacteria.
How is shigellosis transmitted?
Shigellosis is primarily transmitted through the fecal-oral route, often via contaminated food or water. Close contact with infected individuals can also facilitate transmission.
When should I use ICD-10 Code A03.9?
ICD-10 Code A03.9 should be used when diagnosing shigellosis without specifying the type of Shigella involved. It is appropriate for cases where laboratory confirmation is pending or not available.
What is the treatment for shigellosis?
Treatment for shigellosis typically includes antibiotic therapy to reduce the duration of symptoms and prevent complications, along with supportive care to manage dehydration.
