ICD-10 Code B37.42 | Candidal balanitis Symptoms, Diagnosis, Billing

Candidal balanitis is a fungal infection of the glans penis caused by Candida species, commonly Candida albicans. It presents with symptoms such as itching, redness, and discharge. Accurate coding with ICD-10 Code B37.42 is essential for proper diagnosis, documentation, and billing, facilitating effective treatment and public health reporting.

What is ICD-10 Code B37.42 for Candidal balanitis?

ICD-10 Code B37.42 specifically denotes candidal balanitis, an infection characterized by inflammation of the glans penis due to Candida overgrowth. This code should be utilized in clinical documentation when diagnosing patients presenting with symptoms of balanitis, ensuring appropriate billing and treatment protocols are followed.

ICD-10 Code B37.42 – Clinical Definition and Explanation of Candidal balanitis

Candidal balanitis is primarily caused by an overgrowth of Candida species, often due to factors such as poor hygiene, diabetes, or antibiotic use. The condition can lead to significant discomfort and requires medical attention to prevent complications.

Key Clinical Features:

• Erythema and swelling of the glans penis
• Itching and burning sensation
• White, curd-like discharge
• Pain during urination or sexual intercourse

ICD-10 Code B37.42 for Candidal balanitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code B37.42 is utilized to document the patient's symptoms, assessment findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B37.42 for Candidal balanitis Mean in SOAP Notes?

ICD-10 Code B37.42 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of candidal balanitis. This linkage is crucial for continuity of care, supporting accurate billing and compliance with EHR documentation standards.

Treatment Options for ICD-10 Code B37.42 – Candidal balanitis

Candidal balanitis may require urgent medical intervention, particularly in severe cases. Treatment typically involves antifungal therapy and supportive care.

Antibiotic Therapy:

• Topical clotrimazole cream applied twice daily for 1-2 weeks
• Oral fluconazole 150 mg as a single dose for severe cases
• Alternative: Ketoconazole cream applied twice daily for 2 weeks

Supportive Care:

• Maintain proper hygiene and keep the area dry
• Avoid irritants such as soaps or lotions
• Educate on diabetes management if applicable

Infection Control:

• Advise against sexual activity until symptoms resolve
• Encourage partners to seek evaluation if symptomatic
• Implement hygiene measures to prevent recurrence

How to Document Symptoms of Candidal balanitis (ICD-10 B37.42) in SOAP Notes

Subjective:

• Patient reports itching and burning sensation on the glans
• Noted white discharge and redness
• History of recent antibiotic use
• Denies any history of sexually transmitted infections

Objective:

• Erythema and edema observed on examination
• White curd-like discharge present
• No lesions or ulcers noted
• Vital signs within normal limits

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SOAP Note Guidelines for Diagnosing Candidal balanitis (ICD-10 Code B37.42)

Assessment:

• Diagnosis: Candidal balanitis, mild severity
• ICD-10 Code: B37.42
• Contributing factors: Recent antibiotic use, poor hygiene

Plan:

• Initiate topical antifungal treatment with clotrimazole
• Educate patient on hygiene practices and diabetes management
• Schedule follow-up in 1 week to assess treatment response

Treatment & Plan Section for ICD-10 Code B37.42 – Candidal balanitis

• First-line treatment includes topical antifungals such as clotrimazole or miconazole.
• Non-pharmacologic strategies include maintaining genital hygiene and avoiding irritants.
• Monitoring for symptom resolution and potential recurrence is essential.
• Follow-up appointments should be scheduled to ensure effective treatment and management.

Using ICD-10 Code B37.42 for Candidal balanitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings under Subjective (S) and Objective (O).
• Utilize the correct ICD-10 code to support billing for antifungal treatments and consultations.
• Treatment plans should align with clinical guidelines to justify billing and reimbursement.
• Only include CPT codes that are commonly associated with candidal balanitis in billing practices.

Related ICD-10 Codes Often Used with Candidal balanitis

• B37.41 – Candidal vulvitis
• B37.49 – Other candidiasis
• A63.0 – Anogenital candidiasis

ICD-10 Code B37.42 in Medical Billing and Insurance for Candidal balanitis

ICD-10 Code B37.42 is critical in billing for candidal balanitis, particularly in hospital, ER, or infectious disease settings.

Billing Notes:

• Document all relevant symptoms and treatment plans to support the claim.
• Use the code in conjunction with appropriate CPT codes for antifungal treatments.
• Ensure that the diagnosis is clearly linked to the patient's presenting symptoms.

Common CPT Pairings: