ICD-10 Code B38.2 | Pulmonary coccidioidomycosis, unspecified Symptoms, Diagnosis, Billing

Pulmonary coccidioidomycosis, unspecified is a fungal infection caused by Coccidioides species, primarily affecting the lungs. It is clinically significant due to its potential to cause severe respiratory illness and complications. Accurate coding with ICD-10 Code B38.2 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this condition effectively.

What is ICD-10 Code B38.2 for Pulmonary coccidioidomycosis, unspecified?

ICD-10 Code B38.2 represents Pulmonary coccidioidomycosis, unspecified, a respiratory infection caused by inhaling spores of the Coccidioides fungus. This code is used when the specific type of pulmonary coccidioidomycosis is not specified, and it is crucial for clinical documentation and billing when patients present with respiratory symptoms related to this infection.

ICD-10 Code B38.2 – Clinical Definition and Explanation of Pulmonary coccidioidomycosis, unspecified

Pulmonary coccidioidomycosis, unspecified is caused by the inhalation of Coccidioides immitis or Coccidioides posadasii spores, leading to respiratory symptoms. The condition can progress to severe pneumonia or disseminated disease, necessitating prompt medical attention.

Key Clinical Features:

• Common symptoms include cough, fever, chest pain, and difficulty breathing.
• Epidemiologically prevalent in endemic areas, particularly the southwestern United States.
• Can lead to chronic pulmonary complications if not treated appropriately.
• Diagnosis often confirmed through serological tests or imaging studies.

ICD-10 Code B38.2 for Pulmonary coccidioidomycosis, unspecified – SOAP Notes & Clinical Use

ICD-10 Code B38.2 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to pulmonary coccidioidomycosis. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B38.2 for Pulmonary coccidioidomycosis, unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B38.2 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of pulmonary coccidioidomycosis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B38.2 – Pulmonary coccidioidomycosis, unspecified

Prompt treatment of pulmonary coccidioidomycosis is critical to prevent complications. Hospitalization may be required for severe cases.

Antibiotic Therapy:

• Fluconazole: First-line treatment for mild to moderate cases, typically for 3-6 months.
• Itraconazole: Alternative for patients intolerant to fluconazole, duration varies based on clinical response.
• Amphotericin B: Considered for severe or disseminated cases, administered intravenously.

Supportive Care:

• Oxygen therapy for patients with hypoxemia.
• Bronchodilators to relieve bronchospasm.
• Hydration and nutritional support as needed.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate patients on avoiding exposure in endemic areas.
• Monitor for outbreaks and implement public health measures as necessary.

How to Document Symptoms of Pulmonary coccidioidomycosis, unspecified (ICD-10 B38.2) in SOAP Notes

Subjective:

• Patient reports persistent cough with sputum production.
• History of fever and chills over the past week.
• Experiencing chest pain that worsens with deep breaths.
• Recent travel to an endemic area with known Coccidioides exposure.

Objective:

• Auscultation reveals wheezing and decreased breath sounds.
• Respiratory rate: 22 breaths per minute.
• Oxygen saturation: 92% on room air.
• Chest X-ray shows infiltrates consistent with pneumonia.

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SOAP Note Guidelines for Diagnosing Pulmonary coccidioidomycosis, unspecified (ICD-10 Code B38.2)

Assessment:

• Diagnosis: Pulmonary coccidioidomycosis, unspecified, moderate severity.
• ICD-10 Code: B38.2.
• Contributing factors include recent travel to endemic region and immunocompromised status.

Plan:

• Initiate fluconazole therapy for 3 months.
• Educate patient on recognizing worsening symptoms.
• Schedule follow-up in 4 weeks to monitor response to treatment.
• Consider referral to infectious disease specialist if no improvement.

Treatment & Plan Section for ICD-10 Code B38.2 – Pulmonary coccidioidomycosis, unspecified

• First-line pharmacologic treatment includes fluconazole or itraconazole.
• Non-pharmacologic strategies involve patient education on symptom management.
• Monitoring includes regular follow-up visits and imaging as needed.
• Follow-up spirometry to assess lung function improvement.

Using ICD-10 Code B38.2 for Pulmonary coccidioidomycosis, unspecified in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings and documentation.
• Ensure Subjective (S) and Objective (O) sections clearly reflect the diagnosis.
• Align treatment plans with clinical guidelines to support justified billing.
• Document any relevant CPT codes that correspond with the treatment provided.

Related ICD-10 Codes Often Used with Pulmonary coccidioidomycosis, unspecified

• B38.0 – Coccidioidomycosis, pulmonary, acute
• B38.1 – Coccidioidomycosis, pulmonary, chronic
• B38.9 – Coccidioidomycosis, unspecified

ICD-10 Code B38.2 in Medical Billing and Insurance for Pulmonary coccidioidomycosis, unspecified

ICD-10 Code B38.2 is essential for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the use of this code.
• Use in conjunction with appropriate CPT codes for services rendered.
• Ensure that the diagnosis is clearly linked to the patient's presenting symptoms.

Common CPT Pairings: