ICD-10 Code B27.10 | Cytomegaloviral mononucleosis without complications Symptoms, Diagnosis, Billing

Cytomegaloviral mononucleosis without complications is an infectious disease caused by the cytomegalovirus (CMV), characterized by symptoms similar to those of infectious mononucleosis. It is clinically significant due to its potential to cause severe illness in immunocompromised individuals. The ICD-10 Code B27.10 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring proper management and tracking of this viral infection.

What is ICD-10 Code B27.10 for Cytomegaloviral mononucleosis without complications?

ICD-10 Code B27.10 represents Cytomegaloviral mononucleosis without complications, a viral infection caused by cytomegalovirus. This code is used when a patient presents with symptoms of mononucleosis, such as fever, fatigue, and lymphadenopathy, without any associated complications. It is essential for accurate clinical documentation and billing, particularly in outpatient and inpatient settings.

ICD-10 Code B27.10 – Clinical Definition and Explanation of Cytomegaloviral mononucleosis without complications

Cytomegaloviral mononucleosis without complications is primarily caused by cytomegalovirus, a member of the herpesvirus family. The condition typically presents with symptoms resembling those of infectious mononucleosis and requires medical attention to manage symptoms and prevent complications.

Key Clinical Features:

• Fever and malaise
• Lymphadenopathy, particularly in the cervical region
• Sore throat and fatigue
• Hepatosplenomegaly may be present

ICD-10 Code B27.10 for Cytomegaloviral mononucleosis without complications – SOAP Notes & Clinical Use

ICD-10 Code B27.10 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management.

What Does ICD-10 Code B27.10 for Cytomegaloviral mononucleosis without complications Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B27.10 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of cytomegaloviral mononucleosis without complications. This code is crucial for ensuring continuity of care, supporting billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B27.10 – Cytomegaloviral mononucleosis without complications

Management of cytomegaloviral mononucleosis without complications focuses on symptomatic relief and monitoring. Hospitalization may be necessary in severe cases or for immunocompromised patients.

Antibiotic Therapy:

• Antibiotics are not effective against viral infections; antiviral therapy may be considered in severe cases.
• Ganciclovir may be used for immunocompromised patients.
• Duration of antiviral therapy varies based on clinical response.

Supportive Care:

• Hydration and rest are essential.
• Analgesics and antipyretics for fever and discomfort.
• Monitoring for potential complications, especially in high-risk patients.

Infection Control:

• Standard precautions should be followed to prevent transmission.
• Educate patients on hygiene practices to reduce spread.
• Isolation may be necessary during outbreaks in vulnerable populations.

How to Document Symptoms of Cytomegaloviral mononucleosis without complications (ICD-10 B27.10) in SOAP Notes

Subjective:

• Patient reports persistent fatigue and malaise.
• Complaints of sore throat and swollen lymph nodes.
• History of recent viral illness or exposure to infected individuals.
• No significant past medical history noted.

Objective:

• Vital signs: Temperature 101°F, pulse 80 bpm.
• Physical exam reveals cervical lymphadenopathy.
• Hepatosplenomegaly noted on abdominal examination.
• Laboratory tests show elevated liver enzymes and atypical lymphocytes.

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SOAP Note Guidelines for Diagnosing Cytomegaloviral mononucleosis without complications (ICD-10 Code B27.10)

Assessment:

• Diagnosis: Cytomegaloviral mononucleosis without complications.
• Severity: Mild to moderate based on clinical presentation.
• ICD-10 Code: B27.10.
• Contributing factors: Recent viral exposure.

Plan:

• Supportive care: Advise rest and hydration.
• Symptomatic treatment: Recommend analgesics for pain relief.
• Monitor liver function tests and lymphocyte counts.
• Follow-up in one week or sooner if symptoms worsen.

Treatment & Plan Section for ICD-10 Code B27.10 – Cytomegaloviral mononucleosis without complications

• First-line treatment includes supportive care and symptomatic management.
• Educate patients on the importance of hydration and rest.
• Monitor for complications, especially in immunocompromised patients.
• Schedule follow-up appointments to reassess symptoms and laboratory findings.

Using ICD-10 Code B27.10 for Cytomegaloviral mononucleosis without complications in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
• Use the correct ICD-10 code to support billing for outpatient and inpatient services.
• Align treatment plans with clinical guidelines to justify billing.
• Document any relevant patient education provided during the visit.

Related ICD-10 Codes Often Used with Cytomegaloviral mononucleosis without complications

• B27.11 – Cytomegaloviral mononucleosis with complications
• B25.9 – Cytomegalovirus infection, unspecified
• B20 – HIV disease resulting in other specified diseases

ICD-10 Code B27.10 in Medical Billing and Insurance for Cytomegaloviral mononucleosis without complications

ICD-10 Code B27.10 is critical in medical billing, particularly in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of this code.
• Ensure the code is used in appropriate settings, such as outpatient visits or inpatient admissions.
• Include key elements in the chart, such as symptoms, assessment, and treatment plan.

Common CPT Pairings: