ICD-10 Code B25.2 | Cytomegaloviral pancreatitis Symptoms, Diagnosis, Billing

Cytomegaloviral pancreatitis is an inflammatory condition of the pancreas caused by cytomegalovirus (CMV) infection. It is clinically significant due to its potential to cause severe abdominal pain, nausea, and vomiting, leading to complications such as pancreatic necrosis. Accurate coding with ICD-10 Code B25.2 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code B25.2 for Cytomegaloviral pancreatitis?

ICD-10 Code B25.2 specifically denotes Cytomegaloviral pancreatitis, which is a rare but serious complication of CMV infection. This code should be used when documenting cases of pancreatitis that are directly linked to CMV, particularly in immunocompromised patients. Proper use of this code in clinical documentation and billing is crucial for accurate patient care and reimbursement.

ICD-10 Code B25.2 – Clinical Definition and Explanation of Cytomegaloviral pancreatitis

Cytomegaloviral pancreatitis is primarily caused by the reactivation of cytomegalovirus, particularly in immunocompromised individuals such as those with HIV/AIDS or organ transplant recipients. The condition can lead to significant morbidity and requires prompt medical attention to prevent severe complications.

Key Clinical Features:

• Severe abdominal pain, often localized to the epigastric region.
• Nausea and vomiting, which may lead to dehydration.
• Elevated serum amylase and lipase levels indicating pancreatic inflammation.
• Possible fever and signs of systemic infection.
• History of immunosuppression or recent CMV infection.

ICD-10 Code B25.2 for Cytomegaloviral pancreatitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code B25.2 is utilized to document the diagnosis of Cytomegaloviral pancreatitis, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B25.2 for Cytomegaloviral pancreatitis Mean in SOAP Notes?

ICD-10 Code B25.2 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Cytomegaloviral pancreatitis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B25.2 – Cytomegaloviral pancreatitis

Cytomegaloviral pancreatitis often necessitates hospitalization due to the risk of severe complications. Treatment focuses on managing the infection and supporting pancreatic function.

Antibiotic Therapy:

• Ganciclovir: First-line antiviral therapy, typically administered for 2-3 weeks.
• Foscarnet: Alternative for ganciclovir-resistant cases, duration varies based on clinical response.

Supportive Care:

• Intravenous fluids to maintain hydration.
• Nutritional support, possibly via enteral feeding if oral intake is insufficient.
• Pain management with appropriate analgesics.

Infection Control:

• Strict hand hygiene and use of personal protective equipment (PPE) in healthcare settings.
• Isolation precautions for immunocompromised patients to prevent CMV transmission.

How to Document Symptoms of Cytomegaloviral pancreatitis (ICD-10 B25.2) in SOAP Notes

Subjective:

• Patient reports severe abdominal pain, rated 8/10.
• Nausea and vomiting occurring multiple times daily.
• History of recent CMV infection and immunosuppression.
• Patient expresses concern about worsening symptoms.

Objective:

• Vital signs: BP 100/60 mmHg, HR 110 bpm, Temp 101°F.
• Abdominal examination reveals tenderness in the epigastric region.
• Laboratory results show elevated amylase (300 U/L) and lipase (500 U/L).
• CT scan indicates pancreatic inflammation without necrosis.

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SOAP Note Guidelines for Diagnosing Cytomegaloviral pancreatitis (ICD-10 Code B25.2)

Assessment:

• Diagnosis: Cytomegaloviral pancreatitis, moderate severity.
• ICD-10 Code: B25.2.
• Contributing factors: Recent CMV infection and immunocompromised status.
• Monitor for potential complications such as pancreatic necrosis.

Plan:

• Initiate ganciclovir therapy for CMV infection.
• Provide IV fluids and monitor electrolytes.
• Consult gastroenterology for potential endoscopic intervention.
• Schedule follow-up imaging in one week to assess pancreatic status.

Treatment & Plan Section for ICD-10 Code B25.2 – Cytomegaloviral pancreatitis

• Administer ganciclovir as per infectious disease guidelines.
• Implement dietary modifications to manage pancreatic rest.
• Regular monitoring of pancreatic enzymes and clinical status.
• Educate patient on signs of complications and when to seek immediate care.

Using ICD-10 Code B25.2 for Cytomegaloviral pancreatitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
• Use ICD-10 Code B25.2 in conjunction with relevant procedure codes for billing.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any complications or comorbidities that may affect treatment and billing.

Related ICD-10 Codes Often Used with Cytomegaloviral pancreatitis

• B25.0 – Cytomegaloviral disease, unspecified
• B25.1 – Cytomegaloviral pneumonia
• B20 – HIV disease

ICD-10 Code B25.2 in Medical Billing and Insurance for Cytomegaloviral pancreatitis

ICD-10 Code B25.2 is crucial for billing purposes in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the ICD-10 claim.
• Use this code in inpatient settings where CMV-related complications are managed.
• Ensure that the diagnosis is clearly linked to the patient's clinical presentation and history.
• Include any relevant laboratory or imaging results that support the diagnosis.

Common CPT Pairings: