ICD-10 Code B37.9 | Candidiasis, unspecified Symptoms, Diagnosis, Billing

Candidiasis, unspecified, is a fungal infection caused by Candida species, commonly affecting mucosal surfaces, skin, and systemic sites. It is clinically significant due to its potential to cause severe infections, particularly in immunocompromised individuals. The ICD-10 Code B37.9 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate treatment and resource allocation.

What is ICD-10 Code B37.9 for Candidiasis, unspecified?

ICD-10 Code B37.9 represents candidiasis that is unspecified, indicating a fungal infection caused by Candida without further specification of the site or severity. This code is used in clinical documentation and billing when the exact nature of the candidiasis is not detailed, allowing for proper coding and reimbursement while ensuring that the patient's condition is recognized in health records.

ICD-10 Code B37.9 – Clinical Definition and Explanation of Candidiasis, unspecified

Candidiasis, unspecified, is primarily caused by an overgrowth of Candida species, often due to factors such as antibiotic use, immunosuppression, or diabetes. The condition can progress to more severe infections if not treated promptly, necessitating medical attention.

Key Clinical Features:

• Commonly presents with oral thrush, vaginitis, or skin infections.
• Can lead to systemic infections in immunocompromised patients.
• Symptoms may include itching, redness, and discharge.
• Risk factors include antibiotic use, diabetes, and immunosuppression.

ICD-10 Code B37.9 for Candidiasis, unspecified – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code B37.9 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to candidiasis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.

What Does ICD-10 Code B37.9 for Candidiasis, unspecified Mean in SOAP Notes?

ICD-10 Code B37.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of candidiasis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B37.9 – Candidiasis, unspecified

Candidiasis, unspecified, may require urgent treatment, especially in immunocompromised patients. Antifungal therapy is typically indicated.

Antibiotic Therapy:

• Fluconazole: 150 mg orally as a single dose for uncomplicated cases.
• Itraconazole: 200 mg daily for 3 days for certain presentations.
• Voriconazole: 6 mg/kg IV every 12 hours for severe infections.

Supportive Care:

• Maintain good oral hygiene to prevent oral thrush.
• Use topical antifungals for localized skin infections.
• Monitor blood glucose levels in diabetic patients.

Infection Control:

• Implement hand hygiene practices to prevent spread.
• Educate patients on avoiding known triggers.
• Isolate patients with systemic candidiasis in healthcare settings.

How to Document Symptoms of Candidiasis, unspecified (ICD-10 B37.9) in SOAP Notes

Subjective:

• Patient reports itching and discomfort in the genital area.
• History of recent antibiotic use.
• Complaints of white patches in the mouth.
• No known allergies to antifungal medications.

Objective:

• Physical examination reveals erythema and discharge.
• Oral examination shows white lesions on the tongue.
• Vital signs stable: BP 120/80, HR 72, Temp 98.6°F.
• Skin examination shows rash in intertriginous areas.

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SOAP Note Guidelines for Diagnosing Candidiasis, unspecified (ICD-10 Code B37.9)

Assessment:

• Diagnosis: Candidiasis, unspecified, moderate severity.
• ICD-10 Code: B37.9.
• Contributing factors: Recent antibiotic therapy and diabetes.
• No signs of systemic involvement noted.

Plan:

• Initiate fluconazole 150 mg orally as a single dose.
• Educate patient on maintaining good hygiene.
• Schedule follow-up in one week to reassess symptoms.
• Monitor blood glucose levels closely.

Treatment & Plan Section for ICD-10 Code B37.9 – Candidiasis, unspecified

• First-line treatment includes fluconazole or topical antifungals.
• Non-pharmacologic strategies include dietary modifications and hygiene education.
• Monitoring for symptom resolution and potential recurrence is essential.
• Follow-up appointments should be scheduled to evaluate treatment efficacy.

Using ICD-10 Code B37.9 for Candidiasis, unspecified in Billing & SOAP Note Compliance

• Ensure clear documentation of symptoms and treatment rationale.
• Use the code in settings where candidiasis is diagnosed or treated.
• Align treatment plans with clinical guidelines to support billing.
• Document any relevant comorbidities that may affect treatment.

Related ICD-10 Codes Often Used with Candidiasis, unspecified

• B37.0 – Candidiasis of mouth and throat
• B37.1 – Candidiasis of vulva and vagina
• B37.2 – Candidiasis of skin
• B37.3 – Candidiasis of other sites

ICD-10 Code B37.9 in Medical Billing and Insurance for Candidiasis, unspecified

ICD-10 Code B37.9 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use the code in outpatient and inpatient settings as appropriate.
• Ensure that the patient's history and treatment plan are clearly outlined.

Common CPT Pairings: