ICD-10 Code A04.1 | Enterotoxigenic Escherichia coli infection Symptoms, Diagnosis, Billing

Enterotoxigenic Escherichia coli (ETEC) infection is a significant cause of diarrhea, particularly in developing countries and among travelers. It is caused by specific strains of E. coli that produce enterotoxins, leading to watery diarrhea, abdominal cramps, and dehydration. Accurate coding with ICD-10 Code A04.1 is essential for proper diagnosis, documentation, billing, and public health reporting, ensuring that healthcare providers can track and manage this infectious disease effectively.

What is ICD-10 Code A04.1 for Enterotoxigenic Escherichia coli infection?

ICD-10 Code A04.1 specifically denotes Enterotoxigenic Escherichia coli infection, characterized by diarrhea caused by enterotoxins produced by pathogenic E. coli strains. This code should be used in clinical documentation and billing when a patient presents with symptoms consistent with ETEC infection, particularly in cases of travel-related diarrhea or outbreaks.

ICD-10 Code A04.1 – Clinical Definition and Explanation of Enterotoxigenic Escherichia coli infection

Enterotoxigenic Escherichia coli infection is primarily caused by the ingestion of contaminated food or water. The bacteria adhere to the intestinal mucosa and secrete toxins that disrupt normal intestinal function, leading to diarrhea and dehydration. Prompt medical attention is necessary to prevent complications, especially in vulnerable populations.

Key Clinical Features:

• Watery diarrhea, often profuse and without blood
• Abdominal cramps and discomfort
• Nausea and vomiting may occur
• Dehydration signs, such as dry mucous membranes and decreased urine output

ICD-10 Code A04.1 for Enterotoxigenic Escherichia coli infection – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A04.1 is utilized to document the diagnosis of Enterotoxigenic Escherichia coli infection, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute care settings and outpatient follow-ups.

What Does ICD-10 Code A04.1 for Enterotoxigenic Escherichia coli infection Mean in SOAP Notes?

ICD-10 Code A04.1 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of ETEC infection. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A04.1 – Enterotoxigenic Escherichia coli infection

Enterotoxigenic Escherichia coli infection may require hospitalization in severe cases, particularly for dehydration management. Antibiotic therapy may be indicated in certain situations.

Antibiotic Therapy:

• First-line: Ciprofloxacin or Azithromycin for 3-5 days
• Alternative: Rifaximin for non-bloody diarrhea
• Consideration of antibiotic resistance patterns

Supportive Care:

• Oral rehydration solutions to prevent dehydration
• Intravenous fluids for severe dehydration
• Antiemetics for nausea and vomiting management

Infection Control:

• Strict hand hygiene practices
• Isolation of infected patients during outbreaks
• Education on safe food and water consumption

How to Document Symptoms of Enterotoxigenic Escherichia coli infection (ICD-10 A04.1) in SOAP Notes

Subjective:

• Patient reports onset of watery diarrhea after recent travel
• Complaints of abdominal cramps and nausea
• History of consuming street food or untreated water
• No blood in stool noted

Objective:

• Vital signs: Elevated heart rate, low blood pressure
• Physical exam: Dry mucous membranes, decreased skin turgor
• Stool examination: Watery consistency, no leukocytes
• Laboratory tests: Electrolyte imbalance may be present

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SOAP Note Guidelines for Diagnosing Enterotoxigenic Escherichia coli infection (ICD-10 Code A04.1)

Assessment:

• Diagnosis: Enterotoxigenic Escherichia coli infection, moderate severity
• ICD-10 Code: A04.1
• Contributing factors: Recent travel to endemic area, consumption of contaminated food

Plan:

• Initiate oral rehydration therapy; consider IV fluids if severe
• Prescribe Ciprofloxacin for 3 days if indicated
• Educate patient on hygiene and food safety practices
• Schedule follow-up in 48 hours to reassess hydration status

Treatment & Plan Section for ICD-10 Code A04.1 – Enterotoxigenic Escherichia coli infection

• First-line pharmacologic treatment: Ciprofloxacin or Azithromycin
• Non-pharmacologic strategies: Oral rehydration solutions, dietary modifications
• Monitoring practices: Regular assessment of hydration status, electrolyte levels
• Follow-up recommendations: Re-evaluate in 48 hours or sooner if symptoms worsen

Using ICD-10 Code A04.1 for Enterotoxigenic Escherichia coli infection in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical presentation and severity
• Document all symptoms clearly under Subjective (S) and Objective (O) sections
• Ensure treatment plans align with clinical guidelines for justified billing
• Include relevant CPT codes for laboratory tests and consultations

Related ICD-10 Codes Often Used with Enterotoxigenic Escherichia coli infection

• A04.0 – Enteropathogenic Escherichia coli infection
• A04.2 – Enteroinvasive Escherichia coli infection
• A04.3 – Enterohemorrhagic Escherichia coli infection
• A05.0 – Other bacterial foodborne intoxications

ICD-10 Code A04.1 in Medical Billing and Insurance for Enterotoxigenic Escherichia coli infection

ICD-10 Code A04.1 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document patient history, including travel and dietary habits, to support the diagnosis.
• Use the code in conjunction with relevant CPT codes for laboratory tests and treatments.
• Ensure all documentation reflects the severity and complexity of the case.

Common CPT Pairings: