ICD-10 Code B27.90 | Infectious mononucleosis, unspecified without complication Symptoms, Diagnosis, Billing

Infectious mononucleosis, unspecified without complication is primarily caused by the Epstein-Barr virus (EBV) and is characterized by symptoms such as fever, sore throat, and lymphadenopathy. Accurate coding with ICD-10 Code B27.90 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this common viral infection effectively.

What is ICD-10 Code B27.90 for Infectious mononucleosis, unspecified without complication?

ICD-10 Code B27.90 represents Infectious mononucleosis, unspecified without complication, a viral infection typically caused by the Epstein-Barr virus. This code is used when the diagnosis is confirmed but without any specified complications. It is essential for clinical documentation and billing to ensure accurate representation of the patient's condition.

ICD-10 Code B27.90 – Clinical Definition and Explanation of Infectious mononucleosis, unspecified without complication

Infectious mononucleosis, unspecified without complication, is primarily caused by the Epstein-Barr virus and is characterized by a range of symptoms that may require medical evaluation. Early recognition and appropriate management are crucial to prevent complications.

Key Clinical Features:

• Fever and chills, often accompanied by fatigue.
• Sore throat, which may resemble streptococcal pharyngitis.
• Lymphadenopathy, particularly in the cervical region.
• Splenomegaly may occur in some cases.

ICD-10 Code B27.90 for Infectious mononucleosis, unspecified without complication – SOAP Notes & Clinical Use

ICD-10 Code B27.90 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code B27.90 for Infectious mononucleosis, unspecified without complication Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B27.90 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of infectious mononucleosis. This code supports continuity of care, facilitates billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B27.90 – Infectious mononucleosis, unspecified without complication

Management of Infectious mononucleosis typically involves supportive care, as the condition is viral and self-limiting. Hospitalization may be necessary in severe cases.

Antibiotic Therapy:

• Antibiotics are not effective against viral infections; however, secondary bacterial infections may require treatment.
• If bacterial pharyngitis is suspected, consider amoxicillin or penicillin for 10 days.
• Alternative antibiotics include azithromycin or clindamycin for penicillin-allergic patients.

Supportive Care:

• Hydration and rest are crucial for recovery.
• Analgesics such as acetaminophen or ibuprofen can help alleviate fever and sore throat.
• Corticosteroids may be considered in severe cases with significant airway obstruction.

Infection Control:

• Advise patients to avoid sharing utensils or drinks to prevent transmission.
• Educate on the importance of hand hygiene.
• Isolate symptomatic individuals during outbreaks to minimize spread.

How to Document Symptoms of Infectious mononucleosis, unspecified without complication (ICD-10 B27.90) in SOAP Notes

Subjective:

• Patient reports persistent fatigue and malaise for several days.
• Complains of a severe sore throat and difficulty swallowing.
• Noticed swollen lymph nodes in the neck.
• Denies any recent travel or exposure to sick contacts.

Objective:

• Vital signs: Temperature 101°F, heart rate 80 bpm.
• Physical exam reveals posterior cervical lymphadenopathy.
• Throat examination shows erythema and exudate.
• Splenomegaly noted on abdominal palpation.

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SOAP Note Guidelines for Diagnosing Infectious mononucleosis, unspecified without complication (ICD-10 Code B27.90)

Assessment:

• Diagnosis: Infectious mononucleosis, unspecified without complication.
• ICD-10 Code: B27.90.
• Severity: Mild to moderate based on clinical presentation.
• Contributing factors: Recent exposure to EBV.

Plan:

• Initiate supportive care with hydration and analgesics.
• Educate patient on symptom management and when to seek further care.
• Schedule follow-up in one week to reassess symptoms.
• Consider laboratory tests if symptoms worsen or do not improve.

Treatment & Plan Section for ICD-10 Code B27.90 – Infectious mononucleosis, unspecified without complication

• First-line treatment includes hydration and over-the-counter analgesics.
• Monitor for complications such as splenic rupture or airway obstruction.
• Educate on lifestyle modifications to support recovery.
• Follow-up appointments to assess symptom resolution and recovery.

Using ICD-10 Code B27.90 for Infectious mononucleosis, unspecified without complication in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in SOAP notes.
• Use B27.90 when no complications are present to support billing.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant patient history and examination findings to substantiate the diagnosis.

Related ICD-10 Codes Often Used with Infectious mononucleosis, unspecified without complication

• B27.89 – Other infectious mononucleosis
• B19.20 – Chronic viral hepatitis, unspecified

ICD-10 Code B27.90 in Medical Billing and Insurance for Infectious mononucleosis, unspecified without complication

ICD-10 Code B27.90 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient interactions and clinical findings to support the claim.
• Use B27.90 in outpatient settings when no complications are noted.
• Ensure that the diagnosis aligns with the treatment provided for accurate billing.
• Include patient education and follow-up plans in documentation.

Common CPT Pairings: