ICD-10 Code B38.81 | Prostatic coccidioidomycosis Symptoms, Diagnosis, Billing

Prostatic coccidioidomycosis is a rare fungal infection caused by Coccidioides species, primarily affecting the prostate gland. It is clinically significant due to its potential to cause severe complications if left untreated. Accurate coding with ICD-10 Code B38.81 facilitates 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 B38.81 for Prostatic coccidioidomycosis?

ICD-10 Code B38.81 specifically denotes Prostatic coccidioidomycosis, a fungal infection of the prostate. This code should be utilized in clinical documentation and billing when a patient presents with symptoms indicative of this condition, such as pelvic pain or urinary issues, and is confirmed through diagnostic testing.

ICD-10 Code B38.81 – Clinical Definition and Explanation of Prostatic coccidioidomycosis

Prostatic coccidioidomycosis is caused by the inhalation of Coccidioides spores, leading to systemic infection that can localize in the prostate. The condition requires prompt medical attention due to the risk of complications such as abscess formation. Early diagnosis and treatment are crucial for favorable outcomes.

Key Clinical Features:

• Localized pelvic pain or discomfort
• Urinary symptoms such as dysuria or frequency
• Fever and systemic signs of infection
• Possible prostate enlargement on examination

ICD-10 Code B38.81 for Prostatic coccidioidomycosis – SOAP Notes & Clinical Use

ICD-10 Code B38.81 is essential in SOAP notes for documenting the patient's symptoms, assessment findings, and treatment plans related to Prostatic coccidioidomycosis. It is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B38.81 for Prostatic coccidioidomycosis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B38.81 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Prostatic coccidioidomycosis. This code supports continuity of care, facilitates accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B38.81 – Prostatic coccidioidomycosis

Prostatic coccidioidomycosis necessitates urgent medical intervention, often requiring hospitalization for severe cases. Treatment typically involves antifungal therapy and supportive care.

Antibiotic Therapy:

• Fluconazole: 400 mg daily for 6-12 months
• Itraconazole: 200 mg daily for 6-12 months
• Voriconazole: 200 mg twice daily for 6-12 months

Supportive Care:

• Pain management with analgesics
• Hydration and electrolyte balance
• Monitoring for complications such as abscess formation

Infection Control:

• Standard precautions to prevent transmission
• Isolation if necessary during outbreaks
• Education on avoiding exposure to Coccidioides spores

How to Document Symptoms of Prostatic coccidioidomycosis (ICD-10 B38.81) in SOAP Notes

Subjective:

• Patient reports pelvic pain and urinary frequency.
• History of fever and chills over the past week.
• No prior history of prostate issues.
• Recent travel to endemic areas for Coccidioides.

Objective:

• Vital signs: Temperature 101°F, HR 90 bpm.
• Physical exam reveals tender prostate on digital rectal exam.
• Urinalysis shows signs of infection.
• Imaging may reveal prostate enlargement.

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SOAP Note Guidelines for Diagnosing Prostatic coccidioidomycosis (ICD-10 Code B38.81)

Assessment:

• Diagnosis: Prostatic coccidioidomycosis, moderate severity.
• ICD-10 Code: B38.81.
• Contributing factors: Recent travel to endemic region.
• Symptoms consistent with fungal infection.

Plan:

• Initiate antifungal therapy with fluconazole.
• Educate patient on medication adherence and side effects.
• Schedule follow-up in 4 weeks to assess treatment response.
• Consider referral to urology for further evaluation.

Treatment & Plan Section for ICD-10 Code B38.81 – Prostatic coccidioidomycosis

• First-line treatment includes fluconazole or itraconazole.
• Encourage hydration and rest to support recovery.
• Monitor for signs of treatment response or complications.
• Follow-up appointments to reassess symptoms and adjust treatment.

Using ICD-10 Code B38.81 for Prostatic coccidioidomycosis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use B38.81 in appropriate clinical settings, including inpatient and outpatient.
• Align treatment plans with clinical guidelines for justified billing.
• Include relevant CPT codes for services rendered.

Related ICD-10 Codes Often Used with Prostatic coccidioidomycosis

• B38.89 – Other coccidioidomycosis
• B38.81 – Prostatic coccidioidomycosis

ICD-10 Code B38.81 in Medical Billing and Insurance for Prostatic coccidioidomycosis

ICD-10 Code B38.81 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services related to Prostatic coccidioidomycosis.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use B38.81 in inpatient and outpatient settings as appropriate.
• Ensure that treatment plans are clearly outlined in the medical record.
• Include patient education and follow-up plans in documentation.

Common CPT Pairings: