What is ICD-10 Code B00.4 for Herpesviral encephalitis?
ICD-10 Code B00.4 specifically denotes Herpesviral encephalitis, an acute infection of the central nervous system caused by the herpes simplex virus. This code should be utilized in clinical documentation when a patient presents with symptoms indicative of encephalitis, such as fever, seizures, and altered mental status, to ensure appropriate treatment and billing.
ICD-10 Code B00.4 – Clinical Definition and Explanation of Herpesviral encephalitis
Herpesviral encephalitis is primarily caused by the herpes simplex virus type 1 (HSV-1), although type 2 (HSV-2) can also be implicated. The condition progresses rapidly, often leading to severe neurological deficits and requires immediate medical intervention.
Key Clinical Features:
- Fever and headache
- Altered mental status
- Seizures
- Focal neurological deficits
ICD-10 Code B00.4 for Herpesviral encephalitis – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code B00.4 is crucial for documenting the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute care settings, such as emergency departments, and chronic care management.
What Does ICD-10 Code B00.4 for Herpesviral encephalitis Mean in SOAP Notes?
ICD-10 Code B00.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Herpesviral encephalitis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code B00.4 – Herpesviral encephalitis
Herpesviral encephalitis is a medical emergency requiring hospitalization for prompt treatment.
Antibiotic Therapy:
- Acyclovir (first-line) - 10 mg/kg IV every 8 hours for 14-21 days
- Valacyclovir (alternative) - 1 g orally three times daily for 14-21 days
- Foscarnet (alternative) - for resistant cases, dosing varies
Supportive Care:
- Maintain hydration and electrolyte balance
- Monitor neurological status
- Manage fever and pain
Infection Control:
- Implement standard precautions
- Isolate patients if necessary during outbreaks
- Educate staff on transmission risks
How to Document Symptoms of Herpesviral encephalitis (ICD-10 B00.4) in SOAP Notes
Subjective:
- Patient reports fever and severe headache
- Complains of confusion and difficulty concentrating
- History of recent cold sores or genital herpes
- Experiencing seizures
Objective:
- Temperature: 102°F
- Neurological exam shows altered mental status
- CT/MRI shows temporal lobe abnormalities
- CSF analysis reveals elevated white blood cell count
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SOAP Note Guidelines for Diagnosing Herpesviral encephalitis (ICD-10 Code B00.4)
Assessment:
- Diagnosis: Herpesviral encephalitis, severe
- ICD-10 Code: B00.4
- Contributing factors: Recent HSV infection
- Severity: High due to neurological involvement
Plan:
- Initiate acyclovir therapy immediately
- Educate patient on the importance of adherence to antiviral therapy
- Schedule follow-up MRI to assess treatment response
- Monitor for potential complications such as seizures
Treatment & Plan Section for ICD-10 Code B00.4 – Herpesviral encephalitis
- Administer acyclovir as per protocol
- Provide supportive care including hydration
- Educate patient and family about the condition
- Schedule regular follow-up appointments to monitor recovery
Using ICD-10 Code B00.4 for Herpesviral encephalitis in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and treatment
- Use B00.4 in acute care settings for billing
- Align treatment plans with clinical guidelines for justified billing
- Document all relevant findings in Subjective (S) and Objective (O) sections
Related ICD-10 Codes Often Used with Herpesviral encephalitis
- B00.1 – Herpesviral meningitis
- B00.3 – Herpesviral infection, unspecified
- A87.0 – Viral encephalitis, unspecified
ICD-10 Code B00.4 in Medical Billing and Insurance for Herpesviral encephalitis
ICD-10 Code B00.4 is essential for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all clinical findings thoroughly to support the claim
- Use B00.4 in conjunction with relevant CPT codes for comprehensive billing
- Ensure that the diagnosis is clearly linked to the treatment provided
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99284 | Emergency department visit, high severity |
| 70450 | CT scan of the head, without contrast |
| 87491 | HSV testing, PCR |
| 96365 | IV infusion, hydration therapy |
Frequently Asked Questions
Common Questions About Using ICD-10 Code B00.4 for Herpesviral encephalitis
What are the common symptoms of Herpesviral encephalitis?
Common symptoms include fever, headache, confusion, seizures, and focal neurological deficits. Patients may also experience changes in behavior or consciousness.
How is Herpesviral encephalitis diagnosed?
Diagnosis typically involves clinical evaluation, imaging studies like CT or MRI, and lumbar puncture for cerebrospinal fluid analysis to detect the herpes simplex virus.
What is the treatment for Herpesviral encephalitis?
The primary treatment is intravenous acyclovir, which should be initiated as soon as the diagnosis is suspected. Supportive care is also essential.
Is Herpesviral encephalitis contagious?
While the herpes simplex virus can be transmitted through direct contact, Herpesviral encephalitis itself is not contagious. However, the underlying virus can be.
