ICD-10 Code A18.16 | Tuberculosis of cervix Symptoms, Diagnosis, Billing

Tuberculosis of the cervix is a rare but serious form of extrapulmonary tuberculosis caused by Mycobacterium tuberculosis. It can lead to significant morbidity if not diagnosed and treated promptly. The ICD-10 Code A18.16 facilitates accurate diagnosis, documentation, and billing, ensuring proper management of this condition and aiding in public health reporting.

What is ICD-10 Code A18.16 for Tuberculosis of cervix?

ICD-10 Code A18.16 represents Tuberculosis of the cervix, an infection that occurs when Mycobacterium tuberculosis affects the cervical tissue. This code is used in clinical documentation and billing when diagnosing patients with this specific condition, ensuring appropriate treatment and management strategies are implemented.

ICD-10 Code A18.16 – Clinical Definition and Explanation of Tuberculosis of cervix

Tuberculosis of the cervix is primarily caused by the hematogenous spread of Mycobacterium tuberculosis from a primary site, often the lungs. It can progress silently, leading to severe complications if untreated. Prompt medical attention is crucial for effective management.

Key Clinical Features:

• Painless cervical ulceration or lesions
• Possible vaginal discharge or bleeding
• Pelvic pain or discomfort
• History of pulmonary tuberculosis or exposure

ICD-10 Code A18.16 for Tuberculosis of cervix – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A18.16 is utilized to document the diagnosis of Tuberculosis of the cervix, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings.

What Does ICD-10 Code A18.16 for Tuberculosis of cervix Mean in SOAP Notes?

ICD-10 Code A18.16 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Tuberculosis of the cervix. It plays a vital role in ensuring continuity of care, supporting billing processes, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A18.16 – Tuberculosis of cervix

Tuberculosis of the cervix requires urgent medical intervention, often necessitating hospitalization for effective treatment.

Antibiotic Therapy:

• First-line: Isoniazid (INH) for 6-9 months
• First-line: Rifampin for 6-9 months
• Alternative: Ethambutol for 6-9 months
• Alternative: Pyrazinamide may be added in some cases

Supportive Care:

• Pain management with analgesics
• Nutritional support and counseling
• Regular monitoring for treatment response
• Psychosocial support for affected individuals

Infection Control:

• Implement standard precautions to prevent transmission
• Isolation of patients with active pulmonary TB
• Education on hygiene practices to prevent spread
• Regular screening for contacts of infected individuals

How to Document Symptoms of Tuberculosis of cervix (ICD-10 A18.16) in SOAP Notes

Subjective:

• Patient reports painless cervical lesions
• History of recent weight loss and fatigue
• Complaints of abnormal vaginal discharge
• Previous history of pulmonary tuberculosis

Objective:

• Cervical examination reveals ulcerative lesions
• Pelvic ultrasound shows thickened cervical tissue
• Vital signs stable with no fever
• Laboratory tests indicate positive TB culture

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Tuberculosis of cervix (ICD-10 Code A18.16)

Assessment:

• Diagnosis: Tuberculosis of cervix, confirmed by culture
• Severity: Moderate, with potential complications
• ICD-10 Subcode: A18.16
• Contributing factors: History of pulmonary TB

Plan:

• Initiate first-line antibiotic therapy (INH, Rifampin)
• Educate patient on medication adherence and side effects
• Schedule follow-up in 1 month for treatment evaluation
• Consider referral to infectious disease specialist

Treatment & Plan Section for ICD-10 Code A18.16 – Tuberculosis of cervix

• First-line pharmacologic treatments include Isoniazid and Rifampin.
• Non-pharmacologic strategies involve nutritional support and psychosocial counseling.
• Monitoring includes regular follow-up visits and laboratory tests to assess treatment response.
• Follow-up practices should include imaging studies to evaluate cervical lesions.

Using ICD-10 Code A18.16 for Tuberculosis of cervix 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 A18.16 based on standard medical coding practices.

Related ICD-10 Codes Often Used with Tuberculosis of cervix

• A15.0 – Pulmonary tuberculosis, bacteriologically and histologically confirmed
• A18.0 – Tuberculosis of bones and joints
• A18.1 – Tuberculosis of meninges
• A18.2 – Tuberculosis of the genitourinary system

ICD-10 Code A18.16 in Medical Billing and Insurance for Tuberculosis of cervix

ICD-10 Code A18.16 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure thorough documentation of patient history and clinical findings.
• Use this code in conjunction with appropriate CPT codes for services rendered.
• Highlight key chart elements such as diagnostic tests and treatment plans.
• Document any complications or comorbidities to support the claim.

Common CPT Pairings: