Enterocolitis due to Clostridium difficile, recurrent is a significant gastrointestinal condition characterized by inflammation of the colon caused by the bacterium Clostridium difficile. This recurrent form indicates multiple episodes of infection, often following antibiotic treatment. Accurate coding with ICD-10 Code A04.71 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this condition.
What is ICD-10 Code A04.71 for Enterocolitis due to Clostridium difficile, recurrent?
ICD-10 Code A04.71 represents Enterocolitis due to Clostridium difficile, recurrent, which is a serious gastrointestinal infection that can lead to severe complications. This code is used when a patient experiences multiple episodes of enterocolitis caused by C. difficile, often after antibiotic therapy. It is crucial for clinical documentation and billing to accurately reflect the recurrent nature of the condition.
ICD-10 Code A04.71 – Clinical Definition and Explanation of Enterocolitis due to Clostridium difficile, recurrent
Enterocolitis due to Clostridium difficile, recurrent, is primarily caused by the disruption of normal gut flora, often following antibiotic use. The condition can lead to severe diarrhea, abdominal pain, and potentially life-threatening complications. Prompt medical attention is necessary to manage symptoms and prevent further episodes.
Key Clinical Features:
- Recurrent episodes of diarrhea, often watery and foul-smelling.
- Abdominal cramping and tenderness.
- Fever and leukocytosis may be present.
- History of recent antibiotic use or hospitalization.
ICD-10 Code A04.71 for Enterocolitis due to Clostridium difficile, recurrent – SOAP Notes & Clinical Use
ICD-10 Code A04.71 is utilized in SOAP notes to document the patient's symptoms, assessment, and treatment plan for recurrent enterocolitis due to C. difficile. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.
What Does ICD-10 Code A04.71 for Enterocolitis due to Clostridium difficile, recurrent Mean in SOAP Notes?
In SOAP notes, ICD-10 Code A04.71 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of recurrent enterocolitis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code A04.71 – Enterocolitis due to Clostridium difficile, recurrent
Management of recurrent enterocolitis due to Clostridium difficile often requires hospitalization and targeted treatment to prevent complications.
Antibiotic Therapy:
- First-line: Vancomycin 125 mg orally four times daily for 10 days.
- Alternative: Fidaxomicin 200 mg orally twice daily for 10 days.
- Consider prolonged tapering regimens for recurrent cases.
Supportive Care:
- Hydration with oral or intravenous fluids to prevent dehydration.
- Electrolyte replacement as needed.
- Nutritional support may be required in severe cases.
Infection Control:
- Implement contact precautions to prevent spread in healthcare settings.
- Ensure thorough cleaning of surfaces and equipment.
- Educate staff and patients on hygiene practices.
How to Document Symptoms of Enterocolitis due to Clostridium difficile, recurrent (ICD-10 A04.71) in SOAP Notes
Subjective:
- Patient reports recurrent episodes of watery diarrhea.
- Complains of abdominal pain and cramping.
- History of recent antibiotic use.
- Experiencing fever and malaise.
Objective:
- Vital signs: Elevated temperature (e.g., 101°F).
- Abdominal examination: Tenderness in the lower quadrants.
- Laboratory findings: Elevated white blood cell count.
- Stool test positive for C. difficile toxin.
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SOAP Note Guidelines for Diagnosing Enterocolitis due to Clostridium difficile, recurrent (ICD-10 Code A04.71)
Assessment:
- Diagnosis: Recurrent Enterocolitis due to Clostridium difficile, moderate severity.
- ICD-10 Subcode: A04.71.
- Triggers: Recent antibiotic therapy and hospitalization.
- Consideration of underlying health conditions.
Plan:
- Initiate treatment with Vancomycin as per guidelines.
- Educate patient on the importance of hydration.
- Schedule follow-up in one week to reassess symptoms.
- Monitor for potential complications such as colitis.
Treatment & Plan Section for ICD-10 Code A04.71 – Enterocolitis due to Clostridium difficile, recurrent
- First-line pharmacologic treatment: Vancomycin or Fidaxomicin.
- Non-pharmacologic strategies: Hydration and dietary adjustments.
- Monitoring: Regular assessment of stool frequency and consistency.
- Follow-up practices: Schedule reassessment after treatment completion.
Using ICD-10 Code A04.71 for Enterocolitis due to Clostridium difficile, recurrent in Billing & SOAP Note Compliance
- Select accurate subcodes based on clinical severity or complications.
- Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
- Ensure treatment plans align with clinical guidelines to support justified billing.
- Only list CPT codes that are commonly billed with ICD-10 Code A04.71 based on standard medical coding practices.
Related ICD-10 Codes Often Used with Enterocolitis due to Clostridium difficile, recurrent
- A04.7 – Enterocolitis due to Clostridium difficile, unspecified
- A04.72 – Enterocolitis due to Clostridium difficile, initial episode
ICD-10 Code A04.71 in Medical Billing and Insurance for Enterocolitis due to Clostridium difficile, recurrent
ICD-10 Code A04.71 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.
Billing Notes:
- Ensure documentation includes specific symptoms and treatment details.
- Use this code in inpatient and outpatient settings for accurate billing.
- Highlight any complications or recurrent episodes in the medical record.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, low complexity. |
| 99232 | Subsequent hospital care, moderate complexity. |
| 87521 | Infectious agent detection by nucleic acid (DNA or RNA), C. difficile. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A04.71 for Enterocolitis due to Clostridium difficile, recurrent
What are the common symptoms of recurrent C. difficile infection?
Common symptoms include recurrent watery diarrhea, abdominal pain, fever, and nausea. Patients may experience multiple episodes following antibiotic treatment, which can lead to severe dehydration and complications.
How is recurrent C. difficile infection treated?
Treatment typically involves antibiotics such as Vancomycin or Fidaxomicin. In severe cases, hospitalization may be required for intravenous fluids and monitoring.
What precautions should be taken to prevent C. difficile spread?
Infection control measures include hand hygiene, use of gloves and gowns, and thorough cleaning of surfaces. Patients should be isolated in healthcare settings to prevent transmission.
When should ICD-10 Code A04.71 be used?
This code should be used when documenting recurrent episodes of enterocolitis due to C. difficile, particularly after antibiotic therapy. It is essential for accurate billing and treatment planning.
