Tuberculous pleurisy is an inflammatory condition of the pleura caused by Mycobacterium tuberculosis. It is clinically significant as it can lead to pleural effusion and respiratory distress. Accurate coding with ICD-10 Code A15.6 ensures proper diagnosis, documentation, and billing, facilitating effective public health reporting and management of tuberculosis-related complications.
What is ICD-10 Code A15.6 for Tuberculous pleurisy?
ICD-10 Code A15.6 represents Tuberculous pleurisy, a complication of pulmonary tuberculosis characterized by inflammation of the pleura. This code is used when pleurisy is directly linked to tuberculosis infection, ensuring accurate clinical documentation and appropriate billing for healthcare services related to this condition.
ICD-10 Code A15.6 – Clinical Definition and Explanation of Tuberculous pleurisy
Tuberculous pleurisy occurs when the pleura becomes inflamed due to tuberculosis infection, often presenting with pleuritic chest pain and respiratory symptoms. It requires prompt medical attention to prevent complications such as pleural effusion and respiratory failure.
Key Clinical Features:
- Pleuritic chest pain, often worsening with deep breathing or coughing.
- Dry cough or productive cough with possible hemoptysis.
- Fever, night sweats, and weight loss as systemic symptoms.
- Pleural effusion may be detected on imaging studies.
ICD-10 Code A15.6 for Tuberculous pleurisy – SOAP Notes & Clinical Use
ICD-10 Code A15.6 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans for Tuberculous pleurisy. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code A15.6 for Tuberculous pleurisy Mean in SOAP Notes?
In SOAP notes, ICD-10 Code A15.6 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Tuberculous pleurisy. This code supports continuity of care, accurate billing, and compliance with EHR documentation standards.
Treatment Options for ICD-10 Code A15.6 – Tuberculous pleurisy
Tuberculous pleurisy necessitates urgent medical intervention, often requiring hospitalization for effective management.
Antibiotic Therapy:
- First-line: Isoniazid, Rifampin, Pyrazinamide, Ethambutol for a duration of 6-12 months.
- Alternative: Levofloxacin or Moxifloxacin may be used in resistant cases.
Supportive Care:
- Pain management with NSAIDs or opioids as needed.
- Thoracentesis for significant pleural effusion to relieve symptoms.
- Monitoring for respiratory distress and complications.
Infection Control:
- Implement airborne precautions in healthcare settings.
- Educate patients on cough etiquette and hygiene practices.
- Screen close contacts for tuberculosis exposure.
How to Document Symptoms of Tuberculous pleurisy (ICD-10 A15.6) in SOAP Notes
Subjective:
- Patient reports sharp, localized chest pain exacerbated by deep breathing.
- Complaints of persistent cough with occasional blood-tinged sputum.
- History of night sweats and unintentional weight loss over the past month.
- Denies recent travel or known exposure to tuberculosis.
Objective:
- Auscultation reveals decreased breath sounds on the affected side.
- Vital signs: Temperature 100.4°F, Respiratory rate 22 breaths/min.
- Chest X-ray shows pleural effusion on the right side.
- Oxygen saturation at 92% on room air.
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SOAP Note Guidelines for Diagnosing Tuberculous pleurisy (ICD-10 Code A15.6)
Assessment:
- Diagnosis: Tuberculous pleurisy, moderate severity.
- ICD-10 Code: A15.6.
- Contributing factors: Recent history of pulmonary tuberculosis.
- Consideration of pleural effusion requiring further evaluation.
Plan:
- Initiate first-line antibiotic therapy as per tuberculosis treatment guidelines.
- Educate patient on the importance of adherence to medication regimen.
- Schedule follow-up for monitoring response to treatment and repeat imaging.
- Consider referral to a pulmonologist for specialized care.
Treatment & Plan Section for ICD-10 Code A15.6 – Tuberculous pleurisy
- First-line pharmacologic treatments include a combination of isoniazid, rifampin, pyrazinamide, and ethambutol.
- Non-pharmacologic strategies involve patient education on tuberculosis transmission and adherence to treatment.
- Monitoring includes regular follow-up visits to assess treatment efficacy and side effects.
- Follow-up practices may involve repeat chest imaging and laboratory tests to evaluate response.
Using ICD-10 Code A15.6 for Tuberculous pleurisy in Billing & SOAP Note Compliance
- Select accurate subcodes based on clinical severity or complications related to Tuberculous pleurisy.
- Document symptoms clearly under Subjective (S) and Objective (O) sections 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 A15.6 based on standard medical coding practices.
Related ICD-10 Codes Often Used with Tuberculous pleurisy
- A15.0 – Pulmonary tuberculosis, bacteriologically and histologically confirmed
- A15.1 – Pulmonary tuberculosis, not confirmed bacteriologically or histologically
- A15.2 – Tuberculosis of the pleura
- A15.3 – Tuberculosis of the lung, with pleural effusion
ICD-10 Code A15.6 in Medical Billing and Insurance for Tuberculous pleurisy
ICD-10 Code A15.6 is crucial for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Ensure thorough documentation of the patient's history, symptoms, and treatment plan to support the claim.
- Use this code in settings where tuberculosis-related care is provided, including outpatient and inpatient services.
- Highlight key chart elements such as diagnostic imaging and laboratory results that substantiate the diagnosis.
- Verify that the code aligns with the services rendered to avoid claim denials.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, low complexity. |
| 71046 | Chest X-ray, two views. |
| 32555 | Thoracentesis, with or without injection of therapeutic substance. |
| 36415 | Collection of venous blood by venipuncture. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A15.6 for Tuberculous pleurisy
What are the common symptoms of Tuberculous pleurisy?
Common symptoms include sharp chest pain that worsens with breathing, a persistent cough, fever, night sweats, and weight loss. Patients may also experience difficulty breathing if pleural effusion is present.
How is Tuberculous pleurisy diagnosed?
Diagnosis typically involves clinical evaluation, imaging studies such as chest X-rays or CT scans, and laboratory tests including pleural fluid analysis and microbiological cultures to confirm tuberculosis infection.
What is the treatment for Tuberculous pleurisy?
Treatment involves a combination of antibiotics specifically targeting tuberculosis, typically for a duration of 6-12 months. Supportive care may include pain management and procedures to drain pleural effusions if necessary.
Is Tuberculous pleurisy contagious?
While Tuberculous pleurisy itself is not directly contagious, it is a complication of pulmonary tuberculosis, which can be transmitted through airborne particles. Infection control measures are essential to prevent spread.
