ICD-10 Code B38.4 | Coccidioidomycosis meningitis Symptoms, Diagnosis, Billing

Coccidioidomycosis meningitis is a severe fungal infection caused by Coccidioides species, primarily affecting the central nervous system. It is characterized by inflammation of the meninges and can lead to significant morbidity. Accurate coding with ICD-10 Code B38.4 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code B38.4 for Coccidioidomycosis meningitis?

ICD-10 Code B38.4 specifically denotes Coccidioidomycosis meningitis, a complication of coccidioidomycosis that occurs when the fungal infection spreads to the meninges. This code should be used in clinical documentation and billing when a patient presents with neurological symptoms indicative of meningitis related to this fungal infection.

ICD-10 Code B38.4 – Clinical Definition and Explanation of Coccidioidomycosis meningitis

Coccidioidomycosis meningitis arises from the dissemination of Coccidioides fungi, typically following pulmonary infection. The condition can progress rapidly, leading to severe neurological complications, necessitating prompt medical intervention.

Key Clinical Features:

• Fever and headache, often severe.
• Stiff neck and photophobia.
• Altered mental status or confusion.
• Neurological deficits such as weakness or sensory changes.

ICD-10 Code B38.4 for Coccidioidomycosis meningitis – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code B38.4 is utilized to document the diagnosis of Coccidioidomycosis meningitis, 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 B38.4 for Coccidioidomycosis meningitis Mean in SOAP Notes?

ICD-10 Code B38.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Coccidioidomycosis meningitis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B38.4 – Coccidioidomycosis meningitis

Coccidioidomycosis meningitis requires urgent medical attention, often necessitating hospitalization for effective management.

Antibiotic Therapy:

• Fluconazole: 400-800 mg daily for 6-12 months.
• Amphotericin B: 0.5-1 mg/kg/day for severe cases.
• Itraconazole: 200-400 mg daily as an alternative.

Supportive Care:

• Hydration and electrolyte management.
• Symptomatic treatment for headache and fever.
• Monitoring for neurological complications.

Infection Control:

• Standard precautions to prevent transmission.
• Isolation of immunocompromised patients if necessary.
• Education on avoiding exposure in endemic areas.

How to Document Symptoms of Coccidioidomycosis meningitis (ICD-10 B38.4) in SOAP Notes

Subjective:

• Patient reports severe headache and neck stiffness.
• Complaints of fever and chills over the past week.
• History of recent travel to endemic areas.
• Experiencing confusion and difficulty concentrating.

Objective:

• Fever of 102°F on examination.
• Positive Brudzinski's sign.
• Altered mental status observed during assessment.
• Lumbar puncture shows elevated white blood cell count with lymphocytic predominance.

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SOAP Note Guidelines for Diagnosing Coccidioidomycosis meningitis (ICD-10 Code B38.4)

Assessment:

• Diagnosis: Coccidioidomycosis meningitis, moderate severity.
• ICD-10 Code: B38.4.
• Contributing factors: Recent travel to endemic region.
• Symptoms consistent with fungal meningitis.

Plan:

• Initiate fluconazole therapy at 400 mg daily.
• Provide supportive care for fever and hydration.
• Monitor neurological status closely.
• Schedule follow-up lumbar puncture in 2 weeks to assess treatment response.

Treatment & Plan Section for ICD-10 Code B38.4 – Coccidioidomycosis meningitis

• First-line treatment with fluconazole or amphotericin B based on severity.
• Educate patient on the importance of adherence to antifungal therapy.
• Regular monitoring of neurological status and laboratory parameters.
• Follow-up appointments to evaluate treatment efficacy and adjust therapy as needed.

Using ICD-10 Code B38.4 for Coccidioidomycosis meningitis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
• Use B38.4 in conjunction with relevant CPT codes for antifungal therapy administration.
• Document treatment plans that align with clinical guidelines to support justified billing.
• Include patient education and follow-up plans to enhance continuity of care.

Related ICD-10 Codes Often Used with Coccidioidomycosis meningitis

• B38.0 – Coccidioidomycosis, pulmonary
• B38.1 – Coccidioidomycosis, disseminated
• B38.2 – Coccidioidomycosis, cutaneous
• B38.3 – Coccidioidomycosis, other

ICD-10 Code B38.4 in Medical Billing and Insurance for Coccidioidomycosis meningitis

ICD-10 Code B38.4 is crucial for billing in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings and treatment plans to support the ICD-10 claim.
• Use B38.4 in settings where patients present with neurological symptoms related to coccidioidomycosis.
• Ensure that all chart elements, including patient history and treatment response, are clearly recorded.

Common CPT Pairings: