ICD-10 Code B38.1 | Chronic pulmonary coccidioidomycosis Symptoms, Diagnosis, Billing

Chronic pulmonary coccidioidomycosis is a long-term lung infection caused by the fungus Coccidioides immitis, primarily affecting individuals in endemic regions. It can lead to significant respiratory symptoms and complications, necessitating accurate diagnosis and documentation. The ICD-10 Code B38.1 facilitates precise medical billing, clinical decision-making, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code B38.1 for Chronic pulmonary coccidioidomycosis?

ICD-10 Code B38.1 represents Chronic pulmonary coccidioidomycosis, a chronic lung infection resulting from the inhalation of Coccidioides spores. This code should be used when documenting cases of chronic pulmonary involvement, particularly in patients with a history of exposure in endemic areas. Accurate coding is essential for appropriate treatment planning and reimbursement.

ICD-10 Code B38.1 – Clinical Definition and Explanation of Chronic pulmonary coccidioidomycosis

Chronic pulmonary coccidioidomycosis is caused by the inhalation of Coccidioides immitis spores, leading to persistent pulmonary symptoms and potential complications. The condition may progress from acute to chronic forms, requiring medical intervention to prevent further respiratory deterioration. Early recognition and treatment are crucial for patient outcomes.

Key Clinical Features:

• Chronic cough, often productive of sputum
• Dyspnea on exertion or at rest
• Chest pain, particularly with deep breathing
• Fever and night sweats may occur

ICD-10 Code B38.1 for Chronic pulmonary coccidioidomycosis – SOAP Notes & Clinical Use

ICD-10 Code B38.1 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It plays a vital role in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management strategies.

What Does ICD-10 Code B38.1 for Chronic pulmonary coccidioidomycosis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B38.1 connects subjective patient-reported symptoms with objective clinical findings, leading to a formal diagnosis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B38.1 – Chronic pulmonary coccidioidomycosis

Chronic pulmonary coccidioidomycosis may require hospitalization for severe cases, particularly if respiratory function is compromised. Treatment typically involves antifungal therapy and supportive measures.

Antibiotic Therapy:

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

Supportive Care:

• Oxygen therapy for hypoxemia
• Bronchodilators for wheezing
• Corticosteroids for severe inflammation

Infection Control:

• Educate patients on avoiding dust exposure in endemic areas
• Implement precautions in healthcare settings during outbreaks
• Monitor for signs of secondary infections

How to Document Symptoms of Chronic pulmonary coccidioidomycosis (ICD-10 B38.1) in SOAP Notes

Subjective:

• Patient reports persistent cough with yellow sputum.
• Experiences shortness of breath, especially during physical activity.
• History of night sweats and fatigue over the past month.
• No known allergies or recent travel outside endemic areas.

Objective:

• Auscultation reveals wheezing and crackles bilaterally.
• Respiratory rate: 22 breaths per minute.
• Oxygen saturation: 92% on room air.
• Chest X-ray shows infiltrates consistent with fungal infection.

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SOAP Note Guidelines for Diagnosing Chronic pulmonary coccidioidomycosis (ICD-10 Code B38.1)

Assessment:

• Chronic pulmonary coccidioidomycosis, moderate severity.
• ICD-10 Code B38.1.
• Recent exposure to endemic area noted.
• Consideration of immunocompromised status as a contributing factor.

Plan:

• Initiate fluconazole therapy at 400 mg daily.
• Educate patient on recognizing worsening symptoms.
• Schedule follow-up in 4 weeks for reassessment.
• Monitor oxygen saturation and respiratory status regularly.

Treatment & Plan Section for ICD-10 Code B38.1 – Chronic pulmonary coccidioidomycosis

• First-line treatment includes fluconazole or itraconazole.
• Encourage lifestyle modifications, such as smoking cessation.
• Regular monitoring of respiratory function through spirometry.
• Follow-up appointments to assess treatment efficacy and adjust therapy as needed.

Using ICD-10 Code B38.1 for Chronic pulmonary coccidioidomycosis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in both inpatient and outpatient settings for consistency.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Chronic pulmonary coccidioidomycosis

• B38.0 – Acute pulmonary coccidioidomycosis
• B38.9 – Coccidioidomycosis, unspecified

ICD-10 Code B38.1 in Medical Billing and Insurance for Chronic pulmonary coccidioidomycosis

ICD-10 Code B38.1 is crucial for billing purposes, particularly in hospital and infectious disease settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use the code in conjunction with appropriate CPT codes for services rendered.
• Ensure that the patient's history includes exposure to endemic areas.
• Maintain clear records of treatment plans and follow-up care.

Common CPT Pairings: