ICD-10 Code A18.53 | Tuberculous chorioretinitis Symptoms, Diagnosis, Billing

Tuberculous chorioretinitis is an ocular manifestation of tuberculosis, characterized by inflammation of the choroid and retina due to Mycobacterium tuberculosis infection. This condition is clinically significant as it can lead to vision loss if not diagnosed and treated promptly. The ICD-10 Code A18.53 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious disease.

What is ICD-10 Code A18.53 for Tuberculous chorioretinitis?

ICD-10 Code A18.53 represents Tuberculous chorioretinitis, an inflammatory condition of the eye caused by the spread of tuberculosis. This code should be used when documenting cases where the choroid and retina are affected by the tuberculosis infection, particularly in patients with a known history of pulmonary or extrapulmonary tuberculosis. Accurate coding is essential for appropriate clinical documentation and billing.

ICD-10 Code A18.53 – Clinical Definition and Explanation of Tuberculous chorioretinitis

Tuberculous chorioretinitis is primarily caused by the hematogenous spread of Mycobacterium tuberculosis to the eye, leading to inflammation and potential vision impairment. Early recognition and treatment are crucial to prevent complications such as retinal detachment or permanent vision loss.

Key Clinical Features:

• Symptoms may include blurred vision, floaters, and scotomas.
• Fundoscopic examination may reveal choroidal lesions or retinal exudates.
• Associated systemic symptoms may include fever, night sweats, and weight loss.
• Higher prevalence in immunocompromised individuals, particularly those with HIV.

ICD-10 Code A18.53 for Tuberculous chorioretinitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A18.53 is utilized to document the diagnosis of Tuberculous chorioretinitis, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code A18.53 for Tuberculous chorioretinitis Mean in SOAP Notes?

ICD-10 Code A18.53 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Tuberculous chorioretinitis. This linkage is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A18.53 – Tuberculous chorioretinitis

Tuberculous chorioretinitis requires prompt medical intervention, often necessitating hospitalization for severe cases. Treatment typically involves a combination of antibiotic therapy and supportive care.

Antibiotic Therapy:

• First-line: Rifampin, Isoniazid, Pyrazinamide, Ethambutol for 6-12 months.
• Alternative: Streptomycin may be used in resistant cases.
• Duration of therapy is typically 6-12 months depending on clinical response.

Supportive Care:

• Regular ophthalmologic evaluations to monitor vision and retinal health.
• Management of systemic tuberculosis symptoms.
• Patient education on adherence to treatment regimens.

Infection Control:

• Implement standard precautions to prevent transmission.
• Isolation may be necessary for patients with active pulmonary tuberculosis.
• Educate patients on respiratory hygiene and cough etiquette.

How to Document Symptoms of Tuberculous chorioretinitis (ICD-10 A18.53) in SOAP Notes

Subjective:

• Patient reports blurred vision and increased floaters in the left eye.
• History of recent weight loss and night sweats.
• No prior ocular history or trauma reported.
• Patient has a known history of pulmonary tuberculosis.

Objective:

• Visual acuity testing shows 20/40 in the affected eye.
• Fundoscopic examination reveals choroidal lesions.
• No signs of retinal detachment observed.
• Systemic examination shows mild fever and lymphadenopathy.

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 Tuberculous chorioretinitis (ICD-10 Code A18.53)

Assessment:

• Diagnosis: Tuberculous chorioretinitis, moderate severity.
• ICD-10 Code: A18.53.
• Contributing factors include history of pulmonary tuberculosis.
• Monitor for potential complications such as retinal detachment.

Plan:

• Initiate anti-tuberculous therapy with Rifampin and Isoniazid.
• Schedule follow-up ophthalmology appointment in 1 month.
• Educate patient on medication adherence and potential side effects.
• Consider referral to infectious disease specialist for management.

Treatment & Plan Section for ICD-10 Code A18.53 – Tuberculous chorioretinitis

• First-line pharmacologic treatments include Rifampin and Isoniazid.
• Non-pharmacologic strategies involve regular eye examinations and patient education.
• Monitoring includes visual acuity assessments and side effect management.
• Follow-up practices should include tracking treatment adherence and symptom resolution.

Using ICD-10 Code A18.53 for Tuberculous chorioretinitis in Billing & SOAP Note Compliance

• Select appropriate ICD-10 codes based on clinical findings and severity.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Commonly billed CPT codes include those for ophthalmologic evaluations and consultations.

Related ICD-10 Codes Often Used with Tuberculous chorioretinitis

• A15.0 – Pulmonary tuberculosis, bacteriologically and histologically confirmed
• A18.51 – Tuberculosis of the eye
• B90.9 – Sequelae of tuberculosis, unspecified
• Z86.11 – Personal history of tuberculosis

ICD-10 Code A18.53 in Medical Billing and Insurance for Tuberculous chorioretinitis

ICD-10 Code A18.53 is critical in medical billing, particularly in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Ensure thorough documentation of the patient's history and clinical findings to support the ICD-10 claim.
• Use this code in conjunction with relevant CPT codes for comprehensive billing.
• Document all treatment plans and patient education efforts to justify the medical necessity.

Common CPT Pairings: