ICD-10 Code B16.2 | Acute hepatitis B without delta-agent with hepatic coma Symptoms, Diagnosis, Billing

Acute hepatitis B without delta-agent with hepatic coma is a severe liver infection caused by the hepatitis B virus (HBV), characterized by the presence of hepatic coma. This condition is clinically significant due to its potential for rapid deterioration and high mortality rates. The ICD-10 Code B16.2 facilitates accurate diagnosis, documentation, and billing, ensuring appropriate treatment and public health reporting.

What is ICD-10 Code B16.2 for Acute hepatitis B without delta-agent with hepatic coma?

ICD-10 Code B16.2 represents Acute hepatitis B without delta-agent with hepatic coma, indicating a severe form of hepatitis B infection that leads to hepatic failure and coma. This code should be used when documenting cases of acute hepatitis B that result in significant liver dysfunction and altered mental status, ensuring proper coding for treatment and billing purposes.

ICD-10 Code B16.2 – Clinical Definition and Explanation of Acute hepatitis B without delta-agent with hepatic coma

Acute hepatitis B without delta-agent with hepatic coma is primarily caused by the hepatitis B virus, which can lead to acute liver failure and requires immediate medical intervention. The condition progresses rapidly, necessitating hospitalization and intensive care to manage complications effectively.

Key Clinical Features:

• Rapid onset of jaundice and hepatic dysfunction.
• Altered mental status indicating hepatic encephalopathy.
• Coagulopathy and bleeding tendencies due to liver failure.
• Elevated liver enzymes (AST, ALT) and bilirubin levels.

ICD-10 Code B16.2 for Acute hepatitis B without delta-agent with hepatic coma – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code B16.2 is utilized to document the diagnosis of acute hepatitis B with hepatic coma, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute care and chronic management settings.

What Does ICD-10 Code B16.2 for Acute hepatitis B without delta-agent with hepatic coma Mean in SOAP Notes?

ICD-10 Code B16.2 connects subjective patient reports and objective clinical findings to a formal diagnosis of acute hepatitis B with hepatic coma. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B16.2 – Acute hepatitis B without delta-agent with hepatic coma

Acute hepatitis B without delta-agent with hepatic coma requires urgent medical treatment, often necessitating hospitalization for monitoring and supportive care.

Antibiotic Therapy:

• Not applicable as hepatitis B is viral; no antibiotics are indicated.

Supportive Care:

• Intravenous fluids to maintain hydration.
• Nutritional support and monitoring of liver function.
• Management of complications such as coagulopathy.

Infection Control:

• Standard precautions to prevent transmission of hepatitis B.
• Vaccination for at-risk healthcare workers and close contacts.

How to Document Symptoms of Acute hepatitis B without delta-agent with hepatic coma (ICD-10 B16.2) in SOAP Notes

Subjective:

• Patient reports severe fatigue and jaundice.
• History of recent exposure to hepatitis B.
• Complaints of confusion and altered mental status.
• Nausea and vomiting present.

Objective:

• Vital signs: elevated heart rate, low blood pressure.
• Physical exam reveals jaundice and asterixis.
• Laboratory findings: elevated AST, ALT, and bilirubin levels.
• Coagulation studies show prolonged PT/INR.

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SOAP Note Guidelines for Diagnosing Acute hepatitis B without delta-agent with hepatic coma (ICD-10 Code B16.2)

Assessment:

• Diagnosis: Acute hepatitis B without delta-agent with hepatic coma, severe.
• ICD-10 Code: B16.2.
• Contributing factors: Recent exposure to hepatitis B virus.
• Severity: High risk of complications and mortality.

Plan:

• Initiate IV fluids and monitor liver function tests.
• Consult hepatology for potential antiviral therapy.
• Educate patient on the importance of follow-up and monitoring.
• Schedule daily assessments for neurological status.

Treatment & Plan Section for ICD-10 Code B16.2 – Acute hepatitis B without delta-agent with hepatic coma

• Supportive care with IV fluids and nutritional support.
• Monitoring of liver function and coagulation parameters.
• Consultation with specialists for advanced management.
• Patient education on disease progression and prevention.

Using ICD-10 Code B16.2 for Acute hepatitis B without delta-agent with hepatic coma in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in acute care settings for proper billing.
• Align treatment plans with clinical guidelines to justify billing.
• Document all relevant patient history and exposure risks.

Related ICD-10 Codes Often Used with Acute hepatitis B without delta-agent with hepatic coma

• B16.0 – Acute hepatitis B without delta-agent, without hepatic coma

ICD-10 Code B16.2 in Medical Billing and Insurance for Acute hepatitis B without delta-agent with hepatic coma

ICD-10 Code B16.2 is critical in billing for hospitalizations and treatments related to acute hepatitis B with hepatic coma.

Billing Notes:

• Document all clinical findings and treatment plans thoroughly.
• Use the code in emergency and inpatient settings for accurate claims.
• Ensure compliance with coding guidelines to avoid denials.
• Include relevant patient history to support the diagnosis.

Common CPT Pairings: