ICD-10 Code A21.9 | Tularemia, unspecified Symptoms, Diagnosis, Billing

Tularemia, unspecified, is an infectious disease caused by the bacterium Francisella tularensis, primarily transmitted through contact with infected animals or vectors. It is clinically significant due to its potential for severe illness and public health implications. Accurate coding with ICD-10 Code A21.9 ensures proper diagnosis, documentation, medical billing, and facilitates effective public health reporting.

What is ICD-10 Code A21.9 for Tularemia, unspecified?

ICD-10 Code A21.9 represents Tularemia, unspecified, a zoonotic infection characterized by a range of clinical manifestations depending on the route of exposure. This code is used when the specific type of tularemia is not identified. It is essential for clinical documentation and billing when diagnosing patients with suspected or confirmed tularemia without specifying the form.

ICD-10 Code A21.9 – Clinical Definition and Explanation of Tularemia, unspecified

Tularemia, unspecified, is caused by the bacterium Francisella tularensis, which can lead to serious health complications if untreated. The disease can progress rapidly, necessitating prompt medical attention. Early recognition and treatment are crucial to prevent severe outcomes.

Key Clinical Features:

• Fever, chills, and malaise are common initial symptoms.
• Ulceroglandular form presents with skin ulcers and lymphadenopathy.
• Pneumonic tularemia may occur with respiratory symptoms.
• Potential for severe complications if untreated, including sepsis.

ICD-10 Code A21.9 for Tularemia, unspecified – SOAP Notes & Clinical Use

ICD-10 Code A21.9 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and guiding clinical decision-making.

What Does ICD-10 Code A21.9 for Tularemia, unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A21.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of tularemia, unspecified. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A21.9 – Tularemia, unspecified

Hospitalization may be required for severe cases of tularemia. Appropriate antibiotic therapy is critical for effective treatment.

Antibiotic Therapy:

• Streptomycin: 1 g IM every 12 hours for 10 days.
• Gentamicin: 5 mg/kg IV daily for 10 days.
• Doxycycline: 100 mg orally twice daily for 14 days as an alternative.

Supportive Care:

• Hydration and electrolyte management.
• Pain management with analgesics.
• Monitoring for complications such as respiratory distress.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate healthcare staff on handling suspected cases.
• Isolate patients with pneumonic tularemia to prevent airborne spread.

How to Document Symptoms of Tularemia, unspecified (ICD-10 A21.9) in SOAP Notes

Subjective:

• Patient reports fever, chills, and fatigue.
• History of exposure to wild animals or ticks.
• Complaints of painful lymph nodes and skin ulcer.
• Recent travel to endemic areas.

Objective:

• Vital signs: Fever of 102°F, tachycardia.
• Physical exam reveals lymphadenopathy and skin lesions.
• Laboratory tests show leukocytosis.
• Chest X-ray indicates no pulmonary involvement.

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SOAP Note Guidelines for Diagnosing Tularemia, unspecified (ICD-10 Code A21.9)

Assessment:

• Diagnosis: Tularemia, unspecified, moderate severity.
• ICD-10 Code: A21.9.
• Recent exposure to potential sources of infection.
• Symptoms consistent with ulceroglandular tularemia.

Plan:

• Initiate treatment with streptomycin or gentamicin.
• Educate patient on the importance of completing antibiotic therapy.
• Schedule follow-up in one week to monitor progress.
• Consider referral to infectious disease specialist if no improvement.

Treatment & Plan Section for ICD-10 Code A21.9 – Tularemia, unspecified

• First-line treatment includes streptomycin or gentamicin.
• Doxycycline may be used as an alternative for mild cases.
• Patient education on recognizing worsening symptoms.
• Follow-up appointments to assess treatment efficacy and recovery.

Using ICD-10 Code A21.9 for Tularemia, unspecified in Billing & SOAP Note Compliance

• Ensure clear documentation of symptoms and exposure history.
• Use A21.9 when specific type of tularemia is not identified.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant CPT codes for services rendered during the visit.

Related ICD-10 Codes Often Used with Tularemia, unspecified

• A21.0 – Tularemia due to Francisella tularensis, ulceroglandular type
• A21.1 – Tularemia due to Francisella tularensis, glandular type
• A21.2 – Tularemia due to Francisella tularensis, pneumonic type
• A21.8 – Other forms of tularemia

ICD-10 Code A21.9 in Medical Billing and Insurance for Tularemia, unspecified

ICD-10 Code A21.9 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings and patient history.
• Use A21.9 when specific forms of tularemia are not documented.
• Ensure compliance with payer requirements for coding.
• Include detailed notes on treatment plans and patient education.

Common CPT Pairings: