ICD-10 Code A04.6 | Enteritis due to Yersinia enterocolitica Symptoms, Diagnosis, Billing

Enteritis due to Yersinia enterocolitica is an infectious gastrointestinal condition caused by the bacterium Yersinia enterocolitica. It is clinically significant due to its potential to cause severe diarrhea, abdominal pain, and fever, particularly in children. Accurate coding with ICD-10 Code A04.6 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate treatment and resource allocation.

What is ICD-10 Code A04.6 for Enteritis due to Yersinia enterocolitica?

ICD-10 Code A04.6 specifically identifies Enteritis due to Yersinia enterocolitica, a bacterial infection that leads to inflammation of the intestines. This code should be used when documenting cases of enteritis caused by this pathogen, particularly when patients present with gastrointestinal symptoms such as diarrhea and abdominal pain, facilitating accurate billing and clinical management.

ICD-10 Code A04.6 – Clinical Definition and Explanation of Enteritis due to Yersinia enterocolitica

Enteritis due to Yersinia enterocolitica is primarily caused by ingestion of contaminated food or water, often associated with undercooked pork products. The condition can lead to significant gastrointestinal distress and requires prompt medical attention to prevent complications.

Key Clinical Features:

• Acute onset of diarrhea, often bloody
• Abdominal pain and cramping
• Fever and malaise
• Possible complications include reactive arthritis

ICD-10 Code A04.6 for Enteritis due to Yersinia enterocolitica – SOAP Notes & Clinical Use

ICD-10 Code A04.6 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of patients with enteritis due to Yersinia enterocolitica. This code aids in capturing the patient's symptoms, guiding clinical decision-making, and ensuring appropriate billing in both acute and chronic care settings.

What Does ICD-10 Code A04.6 for Enteritis due to Yersinia enterocolitica Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A04.6 connects subjective patient-reported symptoms with objective clinical findings, establishing a formal diagnosis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A04.6 – Enteritis due to Yersinia enterocolitica

Prompt treatment of Enteritis due to Yersinia enterocolitica is essential to manage symptoms and prevent complications. Hospitalization may be required in severe cases.

Antibiotic Therapy:

• Ciprofloxacin 500 mg orally twice daily for 7-14 days
• Trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 7-14 days
• Alternative: Doxycycline 100 mg orally twice daily for 7-14 days

Supportive Care:

• Hydration with oral rehydration solutions or IV fluids if necessary
• Antipyretics for fever management
• Nutritional support as tolerated

Infection Control:

• Strict hand hygiene practices
• Isolation precautions if hospitalized
• Education on food safety to prevent outbreaks

How to Document Symptoms of Enteritis due to Yersinia enterocolitica (ICD-10 A04.6) in SOAP Notes

Subjective:

• Patient reports diarrhea with blood and mucus
• Complaints of severe abdominal cramping
• Fever of 101°F for the past two days
• Recent history of consuming undercooked pork

Objective:

• Vital signs: BP 110/70 mmHg, HR 98 bpm, Temp 101°F
• Abdominal tenderness on palpation, especially in the lower quadrants
• Stool sample positive for Yersinia enterocolitica
• Dehydration noted on examination

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SOAP Note Guidelines for Diagnosing Enteritis due to Yersinia enterocolitica (ICD-10 Code A04.6)

Assessment:

• Diagnosis: Enteritis due to Yersinia enterocolitica, moderate severity
• ICD-10 Code: A04.6
• Common triggers: Consumption of contaminated food
• Consideration of differential diagnoses such as other bacterial enteritides

Plan:

• Initiate antibiotic therapy as per guidelines
• Provide hydration therapy and monitor electrolytes
• Educate patient on dietary modifications during recovery
• Schedule follow-up in 3-5 days to reassess symptoms

Treatment & Plan Section for ICD-10 Code A04.6 – Enteritis due to Yersinia enterocolitica

• First-line antibiotic therapy as indicated
• Encourage fluid intake to prevent dehydration
• Monitor for signs of complications such as septicemia
• Follow-up appointments to ensure resolution of symptoms

Using ICD-10 Code A04.6 for Enteritis due to Yersinia enterocolitica in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes
• Use A04.6 for all cases of enteritis confirmed to be due to Yersinia enterocolitica
• Align treatment plans with clinical guidelines to support billing
• Include relevant CPT codes that correspond to the services provided

Related ICD-10 Codes Often Used with Enteritis due to Yersinia enterocolitica

• A04.0 – Enteritis due to Salmonella
• A04.1 – Enteritis due to Shigella
• A04.2 – Enteritis due to Escherichia coli
• A04.3 – Enteritis due to Campylobacter

ICD-10 Code A04.6 in Medical Billing and Insurance for Enteritis due to Yersinia enterocolitica

ICD-10 Code A04.6 is critical for billing purposes in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the use of A04.6
• Ensure the code is used in conjunction with appropriate CPT codes for services rendered
• Maintain clear records of patient history and treatment plans
• Utilize A04.6 for all confirmed cases of Yersinia enterocolitica enteritis

Common CPT Pairings: