ICD-10 Code B37.0 | Candidal stomatitis Symptoms, Diagnosis, Billing

Candidal stomatitis, commonly known as oral thrush, is a fungal infection caused by the overgrowth of Candida species, particularly Candida albicans. This condition is clinically significant as it can indicate immunocompromised states, especially in individuals with diabetes, HIV, or those on immunosuppressive therapy. Accurate documentation and coding with ICD-10 Code B37.0 facilitate proper diagnosis, billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code B37.0 for Candidal stomatitis?

ICD-10 Code B37.0 represents Candidal stomatitis, a condition characterized by the presence of white patches in the oral cavity due to Candida overgrowth. This code should be used when documenting cases of oral thrush, particularly in patients with risk factors such as immunosuppression or diabetes. Proper use of this code in clinical documentation and billing ensures accurate representation of the patient's condition and supports appropriate treatment plans.

ICD-10 Code B37.0 – Clinical Definition and Explanation of Candidal stomatitis

Candidal stomatitis is primarily caused by an imbalance in the oral microbiome, leading to the proliferation of Candida species. It can progress to more severe infections if left untreated, particularly in immunocompromised patients. Prompt medical attention is essential to prevent complications and manage symptoms effectively.

Key Clinical Features:

• Presence of white, creamy lesions on the tongue and oral mucosa.
• Pain or discomfort in the mouth, especially during eating or swallowing.
• Redness and inflammation of the oral tissues.
• Possible bleeding when lesions are scraped.

ICD-10 Code B37.0 for Candidal stomatitis – SOAP Notes & Clinical Use

ICD-10 Code B37.0 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans for Candidal stomatitis. This code 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 B37.0 for Candidal stomatitis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B37.0 connects subjective reports of symptoms with objective clinical findings, leading to a formal diagnosis of Candidal stomatitis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B37.0 – Candidal stomatitis

Candidal stomatitis requires prompt treatment to alleviate symptoms and prevent complications. Hospitalization may be necessary for severe cases, particularly in immunocompromised patients.

Antibiotic Therapy:

• First-line: Nystatin oral suspension, 400,000 to 600,000 units four times daily for 7-14 days.
• Alternative: Fluconazole 100-200 mg orally once daily for 7-14 days.

Supportive Care:

• Maintain good oral hygiene to reduce fungal growth.
• Use saline mouth rinses to soothe oral lesions.
• Encourage adequate hydration and nutrition.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate patients on hygiene practices to avoid recurrence.
• Monitor for outbreaks in high-risk populations.

How to Document Symptoms of Candidal stomatitis (ICD-10 B37.0) in SOAP Notes

Subjective:

• Patient reports white patches on the tongue and inner cheeks.
• Complains of pain while eating and swallowing.
• History of recent antibiotic use.
• Reports a dry mouth sensation.

Objective:

• White lesions observed on the oral mucosa and tongue.
• Mild erythema noted in the affected areas.
• No signs of systemic infection (e.g., fever, tachycardia).
• Oral examination reveals no other abnormalities.

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SOAP Note Guidelines for Diagnosing Candidal stomatitis (ICD-10 Code B37.0)

Assessment:

• Diagnosis: Candidal stomatitis, mild severity.
• ICD-10 Code: B37.0.
• Contributing factors: Recent antibiotic therapy, possible immunocompromised state.
• Monitor for potential complications.

Plan:

• Initiate treatment with Nystatin oral suspension.
• Educate patient on oral hygiene practices.
• Schedule follow-up in one week to assess treatment response.
• Consider referral to an infectious disease specialist if no improvement.

Treatment & Plan Section for ICD-10 Code B37.0 – Candidal stomatitis

• First-line pharmacologic treatment: Nystatin oral suspension.
• Non-pharmacologic strategies: Good oral hygiene and hydration.
• Monitoring practices: Follow-up appointments to assess treatment efficacy.
• Patient education on recognizing symptoms of recurrence.

Using ICD-10 Code B37.0 for Candidal stomatitis in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings and patient history.
• Document symptoms clearly under Subjective (S) and Objective (O) sections.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Use CPT codes that correspond to the services provided for accurate reimbursement.

Related ICD-10 Codes Often Used with Candidal stomatitis

• B37.1 – Candidal vulvovaginitis
• B37.9 – Candidiasis, unspecified
• B20 – HIV disease

ICD-10 Code B37.0 in Medical Billing and Insurance for Candidal stomatitis

ICD-10 Code B37.0 is essential for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure thorough documentation of symptoms and treatment to support claims.
• Use the code in conjunction with relevant CPT codes for comprehensive billing.
• Document any comorbidities that may affect treatment and billing.

Common CPT Pairings: