ICD-10 Code B37.81 | Candidal esophagitis Symptoms, Diagnosis, Billing

Candidal esophagitis is a fungal infection of the esophagus caused by Candida species, most commonly Candida albicans. It is clinically significant as it can lead to severe dysphagia, chest pain, and systemic infection, particularly in immunocompromised patients. The ICD-10 Code B37.81 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring proper management and treatment of this condition.

What is ICD-10 Code B37.81 for Candidal esophagitis?

ICD-10 Code B37.81 specifically represents candidal esophagitis, an infection characterized by inflammation of the esophagus due to Candida overgrowth. This code should be used in clinical documentation and billing when diagnosing patients with symptoms indicative of esophageal candidiasis, particularly in those with risk factors such as immunosuppression or diabetes.

ICD-10 Code B37.81 – Clinical Definition and Explanation of Candidal esophagitis

Candidal esophagitis is primarily caused by an overgrowth of Candida species in the esophagus, often occurring in immunocompromised individuals. The condition can progress rapidly, leading to significant morbidity if not treated promptly. Medical attention is crucial to prevent complications such as esophageal perforation or systemic candidiasis.

Key Clinical Features:

• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Chest pain or discomfort
• Nausea and vomiting
• Presence of white patches or lesions in the esophagus

ICD-10 Code B37.81 for Candidal esophagitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code B37.81 is utilized to document the diagnosis of candidal esophagitis, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B37.81 for Candidal esophagitis Mean in SOAP Notes?

ICD-10 Code B37.81 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of candidal esophagitis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B37.81 – Candidal esophagitis

Candidal esophagitis often requires urgent medical intervention, particularly in immunocompromised patients. Treatment typically involves antifungal therapy and supportive care.

Antibiotic Therapy:

• Fluconazole (first-line) for 14-21 days
• Itraconazole (alternative) for 14-21 days
• Voriconazole (alternative) for 14-21 days
• Amphotericin B (severe cases)

Supportive Care:

• Hydration and nutritional support
• Pain management with analgesics
• Monitoring for complications
• Education on oral hygiene

Infection Control:

• Implement standard precautions
• Educate staff on infection control measures
• Monitor for outbreaks in healthcare settings

How to Document Symptoms of Candidal esophagitis (ICD-10 B37.81) in SOAP Notes

Subjective:

• Patient reports difficulty swallowing (dysphagia)
• Complaints of chest pain during swallowing (odynophagia)
• History of immunosuppression or diabetes
• Nausea and vomiting noted by the patient

Objective:

• White patches observed on oral examination
• Vital signs stable, no fever
• Esophageal endoscopy shows inflammation and lesions
• Biopsy confirms Candida species

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SOAP Note Guidelines for Diagnosing Candidal esophagitis (ICD-10 Code B37.81)

Assessment:

• Diagnosis: Candidal esophagitis, moderate severity
• ICD-10 Code: B37.81
• Contributing factors: Immunosuppression, diabetes
• Symptoms consistent with esophageal candidiasis

Plan:

• Initiate fluconazole 200 mg daily for 14 days
• Educate patient on oral hygiene practices
• Schedule follow-up appointment in 2 weeks
• Monitor for symptom resolution and potential complications

Treatment & Plan Section for ICD-10 Code B37.81 – Candidal esophagitis

• First-line antifungal therapy with fluconazole
• Supportive care including hydration and pain management
• Patient education on infection prevention
• Follow-up to assess treatment efficacy and symptom resolution

Using ICD-10 Code B37.81 for Candidal esophagitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use B37.81 in conjunction with relevant CPT codes for billing
• Maintain compliance with clinical guidelines for treatment
• Document patient education and follow-up plans clearly

Related ICD-10 Codes Often Used with Candidal esophagitis

• B37.0 – Oral Candidiasis
• B37.9 – Candidiasis, unspecified
• B20 – HIV disease

ICD-10 Code B37.81 in Medical Billing and Insurance for Candidal esophagitis

ICD-10 Code B37.81 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant symptoms and clinical findings thoroughly
• Use B37.81 in appropriate clinical settings to support claims
• Ensure compliance with coding guidelines for accurate billing
• Include patient education and follow-up in documentation

Common CPT Pairings: