ICD-10 Code B38.0 | Acute pulmonary coccidioidomycosis Symptoms, Diagnosis, Billing

Acute pulmonary coccidioidomycosis is a fungal infection caused by Coccidioides species, primarily affecting the lungs. It is clinically significant due to its potential to cause severe respiratory symptoms and complications. Accurate coding with ICD-10 Code B38.0 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this infectious disease.

What is ICD-10 Code B38.0 for Acute pulmonary coccidioidomycosis?

ICD-10 Code B38.0 represents Acute pulmonary coccidioidomycosis, a respiratory illness caused by inhaling spores of the Coccidioides fungus. This code should be used when documenting cases of acute pulmonary infection, particularly in patients presenting with respiratory symptoms following exposure to endemic areas. Proper use of this code is crucial for accurate clinical documentation and billing.

ICD-10 Code B38.0 – Clinical Definition and Explanation of Acute pulmonary coccidioidomycosis

Acute pulmonary coccidioidomycosis is caused by the inhalation of Coccidioides immitis or Coccidioides posadasii spores, leading to an inflammatory response in the lungs. The condition can progress to severe respiratory distress and requires prompt medical attention.

Key Clinical Features:

• Fever and chills
• Cough, often productive
• Chest pain or discomfort
• Shortness of breath

ICD-10 Code B38.0 for Acute pulmonary coccidioidomycosis – SOAP Notes & Clinical Use

ICD-10 Code B38.0 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B38.0 for Acute pulmonary coccidioidomycosis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B38.0 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of acute pulmonary coccidioidomycosis. This ensures continuity of care, supports billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B38.0 – Acute pulmonary coccidioidomycosis

Acute pulmonary coccidioidomycosis may necessitate hospitalization due to respiratory distress. Treatment typically involves antifungal therapy and supportive care.

Antibiotic Therapy:

• Fluconazole: 400-800 mg daily for 3-6 months
• Itraconazole: 200 mg daily for 3-6 months
• Amphotericin B: for severe cases, administered intravenously

Supportive Care:

• Oxygen therapy for hypoxemia
• Bronchodilators for wheezing
• Hydration and rest

Infection Control:

• Isolation precautions in hospital settings
• Education on avoiding exposure in endemic areas
• Monitoring for outbreaks in the community

How to Document Symptoms of Acute pulmonary coccidioidomycosis (ICD-10 B38.0) in SOAP Notes

Subjective:

• Patient reports fever and chills for 3 days.
• Cough with yellow sputum production.
• Experiencing chest pain, especially with deep breaths.
• Shortness of breath worsening with exertion.

Objective:

• Vital signs: Temp 101°F, HR 110 bpm, RR 24 breaths/min.
• Wheezing noted on auscultation.
• Oxygen saturation at 92% on room air.
• Chest X-ray shows infiltrates consistent with pneumonia.

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SOAP Note Guidelines for Diagnosing Acute pulmonary coccidioidomycosis (ICD-10 Code B38.0)

Assessment:

• Diagnosis: Acute pulmonary coccidioidomycosis, moderate severity.
• ICD-10 Code: B38.0.
• Common triggers: Recent travel to endemic area.
• Contributing factors: Immunocompromised status.

Plan:

• Initiate fluconazole 400 mg daily.
• Provide education on recognizing worsening symptoms.
• Schedule follow-up in 1 week to assess treatment response.
• Monitor oxygen saturation and respiratory status closely.

Treatment & Plan Section for ICD-10 Code B38.0 – Acute pulmonary coccidioidomycosis

• First-line treatment with fluconazole or itraconazole.
• Consider hospitalization for severe respiratory symptoms.
• Educate patient on symptom monitoring and when to seek care.
• Follow-up appointments to assess treatment efficacy and adjust as needed.

Using ICD-10 Code B38.0 for Acute pulmonary coccidioidomycosis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use B38.0 in acute care settings for proper billing.
• Align treatment plans with clinical guidelines to support claims.
• Document any complications or comorbidities that may affect billing.

Related ICD-10 Codes Often Used with Acute pulmonary coccidioidomycosis

• B38.1 – Chronic pulmonary coccidioidomycosis
• B38.2 – Coccidioidomycosis with disseminated disease

ICD-10 Code B38.0 in Medical Billing and Insurance for Acute pulmonary coccidioidomycosis

ICD-10 Code B38.0 is critical for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use B38.0 in conjunction with other codes for comprehensive billing.
• Ensure that treatment plans are clearly outlined in the medical record.
• Include patient education and follow-up plans in documentation.

Common CPT Pairings: