ICD-10 Code B27.91 | Infectious mononucleosis, unspecified with polyneuropathy Symptoms, Diagnosis, Billing

Infectious mononucleosis, unspecified with polyneuropathy is a viral infection primarily caused by Epstein-Barr virus (EBV), characterized by fever, sore throat, and lymphadenopathy. The presence of polyneuropathy indicates nerve involvement, which may complicate the clinical picture. Accurate coding with ICD-10 Code B27.91 is essential for proper diagnosis, documentation, billing, and public health reporting, ensuring appropriate patient management and resource allocation.

What is ICD-10 Code B27.91 for Infectious mononucleosis, unspecified with polyneuropathy?

ICD-10 Code B27.91 represents Infectious mononucleosis, unspecified with polyneuropathy, a condition that arises from viral infection, typically EBV. This code should be used when documenting cases of infectious mononucleosis that present with neurological symptoms, indicating nerve damage or dysfunction. It is crucial for accurate clinical documentation and billing, particularly in cases where polyneuropathy is a significant concern.

ICD-10 Code B27.91 – Clinical Definition and Explanation of Infectious mononucleosis, unspecified with polyneuropathy

Infectious mononucleosis, unspecified with polyneuropathy is primarily caused by the Epstein-Barr virus, leading to systemic symptoms and potential neurological complications. The condition necessitates medical attention due to its impact on overall health and the risk of complications. Prompt diagnosis and management are essential to mitigate long-term effects.

Key Clinical Features:

• Fever and fatigue, often prolonged.
• Sore throat and swollen lymph nodes.
• Neurological symptoms such as weakness or sensory changes.
• Elevated liver enzymes indicating hepatic involvement.
• Common in adolescents and young adults.

ICD-10 Code B27.91 for Infectious mononucleosis, unspecified with polyneuropathy – SOAP Notes & Clinical Use

ICD-10 Code B27.91 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of patients with infectious mononucleosis and associated polyneuropathy. This code aids in capturing the complexity of the patient's condition, ensuring comprehensive care in both acute and chronic settings.

What Does ICD-10 Code B27.91 for Infectious mononucleosis, unspecified with polyneuropathy Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B27.91 connects subjective patient-reported symptoms with objective clinical findings, facilitating a formal diagnosis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B27.91 – Infectious mononucleosis, unspecified with polyneuropathy

Management of Infectious mononucleosis, unspecified with polyneuropathy focuses on symptomatic relief and monitoring for complications. Hospitalization may be necessary in severe cases.

Antibiotic Therapy:

• Antibiotics are not typically indicated unless secondary bacterial infections occur.
• Consideration for supportive antibiotics if indicated.

Supportive Care:

• Hydration and rest to support recovery.
• Analgesics for pain relief.
• Corticosteroids may be considered for severe symptoms.

Infection Control:

• Educate patients on avoiding close contact during the infectious period.
• Encourage good hygiene practices to prevent spread.

How to Document Symptoms of Infectious mononucleosis, unspecified with polyneuropathy (ICD-10 B27.91) in SOAP Notes

Subjective:

• Patient reports persistent fatigue and malaise.
• Complaints of severe sore throat and difficulty swallowing.
• History of recent fever and night sweats.
• Neurological symptoms including tingling in extremities.

Objective:

• Fever of 101°F on examination.
• Swollen cervical lymph nodes noted on palpation.
• Hepatomegaly observed during abdominal examination.
• Neurological examination reveals decreased sensation in lower limbs.

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SOAP Note Guidelines for Diagnosing Infectious mononucleosis, unspecified with polyneuropathy (ICD-10 Code B27.91)

Assessment:

• Diagnosis: Infectious mononucleosis with polyneuropathy, moderate severity.
• ICD-10 Code: B27.91.
• Contributing factors: Recent viral infection, potential exposure to EBV.
• Monitor for complications such as splenic rupture.

Plan:

• Pharmacologic treatment: NSAIDs for pain and fever management.
• Patient education on rest and hydration.
• Follow-up in one week to reassess symptoms.
• Consider referral to neurology if neurological symptoms persist.

Treatment & Plan Section for ICD-10 Code B27.91 – Infectious mononucleosis, unspecified with polyneuropathy

• First-line treatment includes NSAIDs for symptomatic relief.
• Encourage adequate hydration and rest.
• Monitor for signs of complications such as splenic enlargement.
• Educate on the importance of follow-up appointments.

Using ICD-10 Code B27.91 for Infectious mononucleosis, unspecified with polyneuropathy in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use B27.91 in settings where polyneuropathy is present.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant patient history to support the diagnosis.

Related ICD-10 Codes Often Used with Infectious mononucleosis, unspecified with polyneuropathy

• B27.90 – Infectious mononucleosis, unspecified without polyneuropathy
• B27.92 – Infectious mononucleosis, unspecified with other complications
• B19.10 – Chronic viral hepatitis B without hepatic coma

ICD-10 Code B27.91 in Medical Billing and Insurance for Infectious mononucleosis, unspecified with polyneuropathy

ICD-10 Code B27.91 is critical in billing for infectious mononucleosis cases, particularly in hospital and ER settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use B27.91 in acute care settings where polyneuropathy is evident.
• Ensure comprehensive documentation to facilitate claims processing.
• Include patient history and treatment plans in the medical record.

Common CPT Pairings: