ICD-10 Code B00.2 | Herpesviral gingivostomatitis and pharyngotonsillitis Symptoms, Diagnosis, Billing

Herpesviral gingivostomatitis and pharyngotonsillitis is an acute viral infection caused primarily by the herpes simplex virus (HSV). It is characterized by inflammation of the gingiva, oral mucosa, and pharynx, leading to painful lesions and systemic symptoms. Accurate coding with ICD-10 Code B00.2 is essential for proper diagnosis, documentation, billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious condition.

What is ICD-10 Code B00.2 for Herpesviral gingivostomatitis and pharyngotonsillitis?

ICD-10 Code B00.2 specifically denotes herpesviral gingivostomatitis and pharyngotonsillitis, which is primarily caused by the herpes simplex virus. This code should be used when documenting cases of oral and pharyngeal lesions associated with HSV infection, ensuring accurate representation of the patient's condition for clinical documentation and billing purposes.

ICD-10 Code B00.2 – Clinical Definition and Explanation of Herpesviral gingivostomatitis and pharyngotonsillitis

Herpesviral gingivostomatitis and pharyngotonsillitis is a viral infection that typically presents in children and can cause significant discomfort and complications. The condition is caused by the herpes simplex virus, which can lead to painful ulcerations in the oral cavity and throat. Prompt medical attention is necessary to manage symptoms and prevent secondary infections.

Key Clinical Features:

• Presence of vesicular lesions on the gums and oral mucosa.
• Severe sore throat and difficulty swallowing.
• Fever and systemic symptoms such as malaise.
• Lymphadenopathy in the cervical region.

ICD-10 Code B00.2 for Herpesviral gingivostomatitis and pharyngotonsillitis – SOAP Notes & Clinical Use

ICD-10 Code B00.2 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of herpesviral gingivostomatitis and pharyngotonsillitis. This code aids in capturing the patient's symptoms, guiding clinical decision-making, and ensuring appropriate billing in both acute and chronic care settings.

What Does ICD-10 Code B00.2 for Herpesviral gingivostomatitis and pharyngotonsillitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B00.2 connects subjective reports of symptoms and objective clinical findings to a formal diagnosis of herpesviral gingivostomatitis and pharyngotonsillitis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B00.2 – Herpesviral gingivostomatitis and pharyngotonsillitis

Management of herpesviral gingivostomatitis and pharyngotonsillitis focuses on symptom relief and preventing complications. Hospitalization may be necessary in severe cases, particularly in immunocompromised patients.

Antibiotic Therapy:

• Acyclovir: 5-10 mg/kg IV every 8 hours for 2-7 days.
• Valacyclovir: 1 g orally three times daily for 7 days.
• Famciclovir: 500 mg orally three times daily for 7 days.

Supportive Care:

• Hydration: Encourage fluid intake to prevent dehydration.
• Pain management: Use analgesics such as acetaminophen or ibuprofen.
• Topical anesthetics: Apply lidocaine gel to relieve oral pain.

Infection Control:

• Practice good hand hygiene to prevent virus transmission.
• Isolate affected individuals during outbreaks.
• Educate patients on avoiding close contact during symptomatic phases.

How to Document Symptoms of Herpesviral gingivostomatitis and pharyngotonsillitis (ICD-10 B00.2) in SOAP Notes

Subjective:

• Patient reports painful sores in the mouth and throat.
• History of fever and malaise for the past three days.
• Difficulty swallowing and increased drooling.
• Recent exposure to another individual with similar symptoms.

Objective:

• Oral examination reveals multiple vesicular lesions on the gingiva.
• Cervical lymphadenopathy noted on palpation.
• Temperature recorded at 101°F.
• Dehydration signs observed, including dry mucous membranes.

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SOAP Note Guidelines for Diagnosing Herpesviral gingivostomatitis and pharyngotonsillitis (ICD-10 Code B00.2)

Assessment:

• Diagnosis: Herpesviral gingivostomatitis and pharyngotonsillitis, moderate severity.
• ICD-10 Code: B00.2.
• Contributing factors: Recent exposure to HSV, immunocompromised status.
• Symptoms consistent with viral infection.

Plan:

• Initiate antiviral therapy with acyclovir.
• Provide education on hydration and pain management.
• Schedule follow-up in 3-5 days to reassess symptoms.
• Monitor for potential complications such as secondary bacterial infections.

Treatment & Plan Section for ICD-10 Code B00.2 – Herpesviral gingivostomatitis and pharyngotonsillitis

• First-line antiviral treatment with acyclovir or valacyclovir.
• Supportive care including hydration and analgesics.
• Education on symptom management and infection control.
• Follow-up appointments to monitor recovery and complications.

Using ICD-10 Code B00.2 for Herpesviral gingivostomatitis and pharyngotonsillitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in appropriate clinical settings, including outpatient and inpatient care.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes for services rendered alongside the diagnosis.

Related ICD-10 Codes Often Used with Herpesviral gingivostomatitis and pharyngotonsillitis

• B00.1 – Herpesviral vesicular stomatitis
• B00.3 – Herpesviral infection of the skin and mucous membranes
• B00.4 – Herpesviral encephalitis
• B00.9 – Herpesviral infection, unspecified

ICD-10 Code B00.2 in Medical Billing and Insurance for Herpesviral gingivostomatitis and pharyngotonsillitis

ICD-10 Code B00.2 is critical in medical billing, particularly in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant symptoms and clinical findings to support the diagnosis.
• Use the code in settings where herpesviral infections are treated, ensuring compliance with billing standards.
• Include detailed notes on treatment plans and patient education to justify claims.
• Ensure that the diagnosis aligns with the services provided for accurate reimbursement.

Common CPT Pairings: