ICD-10 Code A23.9 | Brucellosis, unspecified Symptoms, Diagnosis, Billing

Brucellosis, unspecified is an infectious disease caused by the Brucella species, typically transmitted from animals to humans through unpasteurized dairy products or direct contact with infected animals. This condition is clinically significant due to its potential to cause severe complications, including chronic fatigue and arthritis. The ICD-10 Code A23.9 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track cases of this zoonotic infection.

What is ICD-10 Code A23.9 for Brucellosis, unspecified?

ICD-10 Code A23.9 represents Brucellosis, unspecified, a bacterial infection caused by Brucella species. This code is used when the specific type of Brucella is not identified or documented. It is essential for clinical documentation and billing when patients present with symptoms consistent with brucellosis, allowing for appropriate treatment and tracking of the disease's prevalence.

ICD-10 Code A23.9 – Clinical Definition and Explanation of Brucellosis, unspecified

Brucellosis, unspecified is primarily caused by the Brucella bacteria, which can infect humans through consumption of contaminated food or direct contact with infected animals. The disease can progress to chronic conditions if not treated promptly, necessitating medical attention to prevent complications.

Key Clinical Features:

• Fever, chills, and night sweats.
• Fatigue and malaise.
• Muscle and joint pain.
• Anorexia and weight loss.

ICD-10 Code A23.9 for Brucellosis, unspecified – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A23.9 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to brucellosis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code A23.9 for Brucellosis, unspecified Mean in SOAP Notes?

ICD-10 Code A23.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of brucellosis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A23.9 – Brucellosis, unspecified

Brucellosis, unspecified requires prompt medical intervention to prevent complications. Hospitalization may be necessary for severe cases, and appropriate antibiotic therapy is critical.

Antibiotic Therapy:

• Doxycycline 100 mg orally twice daily for 6 weeks.
• Rifampin 600 mg orally daily for 6 weeks.
• Gentamicin 5 mg/kg IV daily for 7 days (alternative).
• Streptomycin 1 g IM daily for 7 days (alternative).

Supportive Care:

• Hydration and nutritional support.
• Pain management with NSAIDs.
• Monitoring for complications such as osteoarticular involvement.

Infection Control:

• Implement standard precautions in healthcare settings.
• Educate patients on avoiding unpasteurized dairy products.
• Report cases to public health authorities during outbreaks.

How to Document Symptoms of Brucellosis, unspecified (ICD-10 A23.9) in SOAP Notes

Subjective:

• Patient reports fever and chills for the past week.
• Complains of joint pain and fatigue.
• History of consuming unpasteurized dairy products.
• Experiencing night sweats and weight loss.

Objective:

• Temperature: 101°F.
• Joint tenderness noted on examination.
• Mild splenomegaly observed.
• Laboratory tests show elevated white blood cell count.

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SOAP Note Guidelines for Diagnosing Brucellosis, unspecified (ICD-10 Code A23.9)

Assessment:

• Diagnosis: Brucellosis, unspecified, moderate severity.
• ICD-10 Code: A23.9.
• Contributing factors: Recent travel to endemic area, consumption of unpasteurized dairy.
• Symptoms consistent with acute brucellosis.

Plan:

• Initiate antibiotic therapy with doxycycline and rifampin.
• Educate patient on dietary precautions.
• Schedule follow-up in 2 weeks to monitor response to treatment.
• Consider referral to infectious disease specialist if symptoms persist.

Treatment & Plan Section for ICD-10 Code A23.9 – Brucellosis, unspecified

• First-line pharmacologic treatment includes doxycycline and rifampin.
• Non-pharmacologic strategies involve patient education on prevention.
• Monitoring includes regular follow-up visits to assess treatment efficacy.
• Consider additional imaging or lab tests if symptoms do not improve.

Using ICD-10 Code A23.9 for Brucellosis, unspecified in Billing & SOAP Note Compliance

• Select appropriate documentation that clearly outlines symptoms and treatment.
• Ensure code usage aligns with clinical findings in the SOAP notes.
• Maintain compliance with billing standards by documenting all relevant patient interactions.
• Use only valid CPT codes that correspond with the services provided.

Related ICD-10 Codes Often Used with Brucellosis, unspecified

• A23.0 – Brucellosis due to Brucella abortus
• A23.1 – Brucellosis due to Brucella melitensis
• A23.2 – Brucellosis due to Brucella suis
• A23.8 – Other brucellosis

ICD-10 Code A23.9 in Medical Billing and Insurance for Brucellosis, unspecified

ICD-10 Code A23.9 is critical for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all patient encounters thoroughly to support the use of A23.9.
• Ensure that the diagnosis aligns with the clinical findings in the medical record.
• Use A23.9 in conjunction with other relevant codes for comprehensive billing.
• Be aware of payer-specific guidelines for coding brucellosis.

Common CPT Pairings: