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ICD-10 Code A31.0 | Pulmonary mycobacterial infection Symptoms, Diagnosis, Billing

Pulmonary mycobacterial infection is caused by non-tuberculous mycobacteria, primarily affecting the lungs. It is clinically significant due to its potential to cause chronic respiratory symptoms and complications. Accurate coding with ICD-10 Code A31.0 ensures proper diagnosis, documentation, and billing, facilitating effective public health reporting and resource allocation.

What is ICD-10 Code A31.0 for Pulmonary mycobacterial infection?

ICD-10 Code A31.0 represents Pulmonary mycobacterial infection, which is primarily caused by non-tuberculous mycobacteria such as Mycobacterium avium complex. This code should be used in clinical documentation and billing when a patient presents with respiratory symptoms associated with this infection, ensuring accurate tracking and management of the condition.

ICD-10 Code A31.0 – Clinical Definition and Explanation of Pulmonary mycobacterial infection

Pulmonary mycobacterial infection is characterized by the presence of non-tuberculous mycobacteria in the lungs, leading to respiratory symptoms and potential lung damage. It requires medical attention due to its chronic nature and the risk of complications.

Key Clinical Features:

  • Chronic cough, often productive of sputum
  • Fatigue and weight loss
  • Hemoptysis (coughing up blood)
  • Radiographic findings of pulmonary nodules or cavitary lesions

ICD-10 Code A31.0 for Pulmonary mycobacterial infection – SOAP Notes & Clinical Use

ICD-10 Code A31.0 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 patient management.

What Does ICD-10 Code A31.0 for Pulmonary mycobacterial infection Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A31.0 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis, ensuring continuity of care and supporting accurate billing and EHR documentation.

Treatment Options for ICD-10 Code A31.0 – Pulmonary mycobacterial infection

Pulmonary mycobacterial infection requires prompt treatment to prevent progression and complications. Hospitalization may be necessary for severe cases.

Antibiotic Therapy:

  • Azithromycin: 500 mg daily
  • Rifampin: 10 mg/kg daily
  • Ethambutol: 15 mg/kg daily
  • Alternative: Clarithromycin if azithromycin is not tolerated

Supportive Care:

  • Symptomatic relief with bronchodilators
  • Nutritional support for weight loss
  • Pulmonary rehabilitation as needed

Infection Control:

  • Implement airborne precautions in healthcare settings
  • Educate patients on hygiene practices to prevent spread
  • Monitor for outbreaks in community settings

How to Document Symptoms of Pulmonary mycobacterial infection (ICD-10 A31.0) in SOAP Notes

Subjective:

  • Patient reports chronic cough with sputum production
  • History of weight loss and fatigue over the past month
  • Occasional hemoptysis noted by the patient
  • No known exposure to tuberculosis

Objective:

  • Wheezing noted on auscultation
  • Respiratory rate: 22 breaths per minute
  • Oxygen saturation: 92% on room air
  • Chest X-ray shows cavitary lesions in the right upper lobe
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SOAP Note Guidelines for Diagnosing Pulmonary mycobacterial infection (ICD-10 Code A31.0)

Assessment:

  • Diagnosis: Pulmonary mycobacterial infection, moderate severity
  • ICD-10 Code: A31.0
  • Contributing factors: History of chronic lung disease
  • Triggers: Possible exposure to contaminated water sources

Plan:

  • Initiate antibiotic therapy with azithromycin and rifampin
  • Educate patient on medication adherence and potential side effects
  • Schedule follow-up appointment in 4 weeks to monitor response
  • Consider referral to pulmonology for further evaluation

Treatment & Plan Section for ICD-10 Code A31.0 – Pulmonary mycobacterial infection

  • First-line pharmacologic treatments include azithromycin and rifampin.
  • Non-pharmacologic strategies involve nutritional support and pulmonary rehabilitation.
  • Monitoring practices include regular follow-up visits and chest imaging.
  • Educate patients on recognizing worsening symptoms and when to seek care.

Using ICD-10 Code A31.0 for Pulmonary mycobacterial infection in Billing & SOAP Note Compliance

  • Select appropriate 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.
  • Commonly billed CPT codes include those for chest X-rays and pulmonary function tests.

ICD-10 Code A31.0 in Medical Billing and Insurance for Pulmonary mycobacterial infection

ICD-10 Code A31.0 is crucial for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

  • Ensure documentation includes detailed patient history and clinical findings.
  • Use the code in settings where pulmonary mycobacterial infection is diagnosed or treated.
  • Highlight key chart elements such as imaging results and treatment plans.

Common CPT Pairings:

CPT CodeDescription
71045Radiologic examination, chest, single view
94640Pressurized inhalation treatment for asthma or COPD
99214Established patient office visit, moderate complexity

Frequently Asked Questions

Common Questions About Using ICD-10 Code A31.0 for Pulmonary mycobacterial infection

What are the common symptoms of pulmonary mycobacterial infection?

Common symptoms include chronic cough, sputum production, fatigue, weight loss, and hemoptysis. Patients may also experience chest pain and difficulty breathing.

How is pulmonary mycobacterial infection diagnosed?

Diagnosis typically involves clinical evaluation, imaging studies such as chest X-rays or CT scans, and microbiological testing of sputum samples for non-tuberculous mycobacteria.

What is the treatment for pulmonary mycobacterial infection?

Treatment usually involves a combination of antibiotics such as azithromycin and rifampin, along with supportive care. Duration of therapy may vary based on clinical response.

Is pulmonary mycobacterial infection contagious?

Pulmonary mycobacterial infections are generally not considered contagious like tuberculosis. However, precautions should be taken to prevent transmission in healthcare settings.

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