ICD-10 Code B25.1 | Cytomegaloviral hepatitis Symptoms, Diagnosis, Billing

Cytomegaloviral hepatitis is a liver inflammation caused by the cytomegalovirus (CMV), primarily affecting immunocompromised individuals. It can lead to significant morbidity and mortality if not diagnosed and treated promptly. The ICD-10 Code B25.1 facilitates accurate diagnosis, documentation, and billing, ensuring proper management and reporting of this infectious disease.

What is ICD-10 Code B25.1 for Cytomegaloviral hepatitis?

ICD-10 Code B25.1 represents Cytomegaloviral hepatitis, an infection of the liver caused by the cytomegalovirus. This code is used when documenting cases of hepatitis linked to CMV, particularly in patients with weakened immune systems. It is essential for accurate clinical documentation and billing, ensuring appropriate treatment and follow-up.

ICD-10 Code B25.1 – Clinical Definition and Explanation of Cytomegaloviral hepatitis

Cytomegaloviral hepatitis is caused by the cytomegalovirus, which can lead to liver inflammation, particularly in immunocompromised patients such as those with HIV/AIDS or organ transplant recipients. The condition can progress rapidly, necessitating medical intervention to prevent severe complications.

Key Clinical Features:

• Elevated liver enzymes (ALT, AST) indicating liver inflammation.
• Symptoms may include jaundice, fatigue, and abdominal pain.
• Common in immunocompromised individuals, particularly those with HIV.
• Potential for severe liver damage if untreated.

ICD-10 Code B25.1 for Cytomegaloviral hepatitis – SOAP Notes & Clinical Use

ICD-10 Code B25.1 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of Cytomegaloviral hepatitis. It plays a crucial role in both acute and chronic care settings, ensuring comprehensive patient management and accurate billing.

What Does ICD-10 Code B25.1 for Cytomegaloviral hepatitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B25.1 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Cytomegaloviral hepatitis. This code is vital for ensuring continuity of care, supporting billing processes, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B25.1 – Cytomegaloviral hepatitis

Cytomegaloviral hepatitis often requires hospitalization due to the risk of severe liver damage. Antiviral therapy is the primary treatment approach.

Antibiotic Therapy:

• Ganciclovir: First-line treatment, typically administered intravenously.
• Foscarnet: Alternative for resistant cases, given intravenously.
• Duration of therapy varies based on clinical response.

Supportive Care:

• Hydration and electrolyte management.
• Monitoring liver function tests regularly.
• Symptomatic treatment for fever and pain.

Infection Control:

• Standard precautions to prevent transmission.
• Isolation may be necessary in severe cases.
• Education on hygiene practices for patients and caregivers.

How to Document Symptoms of Cytomegaloviral hepatitis (ICD-10 B25.1) in SOAP Notes

Subjective:

• Patient reports fatigue and jaundice.
• History of recent immunosuppressive therapy.
• Complaints of abdominal discomfort.
• No prior history of liver disease.

Objective:

• Elevated liver enzymes (ALT: 150 U/L, AST: 180 U/L).
• Physical exam reveals jaundice and hepatomegaly.
• Vital signs stable; no fever noted.
• Liver ultrasound shows mild hepatomegaly.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Cytomegaloviral hepatitis (ICD-10 Code B25.1)

Assessment:

• Diagnosis: Cytomegaloviral hepatitis, moderate severity.
• ICD-10 Code: B25.1.
• Contributing factors: Immunocompromised state due to recent chemotherapy.
• Monitor for potential complications such as liver failure.

Plan:

• Initiate antiviral therapy with ganciclovir.
• Educate patient on signs of worsening liver function.
• Schedule follow-up in one week for liver function tests.
• Consider referral to infectious disease specialist.

Treatment & Plan Section for ICD-10 Code B25.1 – Cytomegaloviral hepatitis

• First-line pharmacologic treatment: Ganciclovir.
• Non-pharmacologic strategies: Nutritional support and hydration.
• Monitoring: Regular liver function tests and clinical assessments.
• Follow-up: Weekly until stable, then biweekly.

Using ICD-10 Code B25.1 for Cytomegaloviral hepatitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use B25.1 in all relevant encounters to support billing.
• Align treatment plans with clinical guidelines for justification.
• Document any complications or comorbidities for comprehensive coding.

Related ICD-10 Codes Often Used with Cytomegaloviral hepatitis

• B25.0 – Cytomegaloviral infection of other organs
• B20 – HIV disease

ICD-10 Code B25.1 in Medical Billing and Insurance for Cytomegaloviral hepatitis

ICD-10 Code B25.1 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use B25.1 in inpatient and outpatient settings for accurate claims.
• Ensure all chart elements align with coding standards.
• Review payer-specific guidelines for additional documentation requirements.

Common CPT Pairings: