Coccidioidomycosis, unspecified, is a fungal infection caused by the Coccidioides species, primarily affecting the lungs. It is clinically significant due to its potential to cause severe respiratory illness and disseminated disease, particularly in immunocompromised individuals. The ICD-10 Code B38.9 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and resource allocation.
What is ICD-10 Code B38.9 for Coccidioidomycosis, unspecified?
ICD-10 Code B38.9 represents Coccidioidomycosis, unspecified, indicating a fungal infection without specific details regarding its manifestation. This code is used when the clinical presentation does not allow for a more precise classification, and it is essential for documenting cases of coccidioidomycosis in clinical settings, ensuring proper billing and compliance with healthcare regulations.
ICD-10 Code B38.9 – Clinical Definition and Explanation of Coccidioidomycosis, unspecified
Coccidioidomycosis, unspecified, is caused by inhalation of spores from the Coccidioides fungus, commonly found in arid regions. The infection can progress from mild respiratory symptoms to severe pulmonary disease or disseminated infection, necessitating medical intervention.
Key Clinical Features:
- Fever and chills
- Cough and chest pain
- Fatigue and malaise
- Erythema nodosum or rash
ICD-10 Code B38.9 for Coccidioidomycosis, unspecified – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code B38.9 is utilized to document the patient's symptoms, assessment findings, and treatment plans related to coccidioidomycosis. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code B38.9 for Coccidioidomycosis, unspecified Mean in SOAP Notes?
ICD-10 Code B38.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of coccidioidomycosis. It plays a crucial role in ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code B38.9 – Coccidioidomycosis, unspecified
Coccidioidomycosis may require hospitalization, especially in severe cases. Treatment typically involves antifungal therapy and supportive care.
Antibiotic Therapy:
- Fluconazole (first-line) for 3-6 months
- Itraconazole (alternative) for 3-6 months
- Amphotericin B for severe cases
- Voriconazole (alternative) for refractory cases
Supportive Care:
- Hydration and electrolyte management
- Oxygen therapy for respiratory distress
- Pain management
- Monitoring for complications
Infection Control:
- Standard precautions in healthcare settings
- Isolation if disseminated disease is suspected
- Education on avoiding exposure in endemic areas
How to Document Symptoms of Coccidioidomycosis, unspecified (ICD-10 B38.9) in SOAP Notes
Subjective:
- Patient reports persistent cough
- History of fever and chills
- Complaints of fatigue and malaise
- Recent travel to endemic area
Objective:
- Fever of 101°F
- Wheezing on auscultation
- Decreased oxygen saturation at 92%
- Chest X-ray showing infiltrates
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SOAP Note Guidelines for Diagnosing Coccidioidomycosis, unspecified (ICD-10 Code B38.9)
Assessment:
- Diagnosis: Coccidioidomycosis, unspecified, moderate severity
- ICD-10 Code: B38.9
- Contributing factors: Recent travel to endemic area
- Possible immunocompromised status
Plan:
- Initiate fluconazole therapy
- Educate patient on symptom monitoring
- Schedule follow-up in 2 weeks
- Consider referral to infectious disease specialist if no improvement
Treatment & Plan Section for ICD-10 Code B38.9 – Coccidioidomycosis, unspecified
- First-line antifungal therapy with fluconazole
- Patient education on recognizing worsening symptoms
- Regular follow-up appointments to monitor treatment response
- Consider lifestyle modifications to enhance immune function
Using ICD-10 Code B38.9 for Coccidioidomycosis, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings
- Use B38.9 in conjunction with relevant CPT codes for billing
- Maintain compliance with coding guidelines to support claims
- Document treatment plans that align with clinical guidelines
Related ICD-10 Codes Often Used with Coccidioidomycosis, unspecified
- B38.0 – Coccidioidomycosis, pulmonary
- B38.1 – Coccidioidomycosis, disseminated
- B44.9 – Fungal infection, unspecified
ICD-10 Code B38.9 in Medical Billing and Insurance for Coccidioidomycosis, unspecified
ICD-10 Code B38.9 is crucial for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant clinical findings to support the diagnosis
- Use B38.9 in appropriate clinical contexts to avoid claim denials
- Ensure that treatment plans are clearly outlined in the medical record
- Include patient history and travel exposure in documentation
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, level 3 |
| 36415 | Collection of venous blood by venipuncture |
| 71046 | Chest X-ray, 2 views, frontal and lateral |
| 87481 | Infectious agent detection by nucleic acid (DNA or RNA), Coccidioides species |
Frequently Asked Questions
Common Questions About Using ICD-10 Code B38.9 for Coccidioidomycosis, unspecified
What are the common symptoms of coccidioidomycosis?
Common symptoms include fever, cough, chest pain, fatigue, and in some cases, a rash. Symptoms can vary in severity and may resemble other respiratory infections.
Is coccidioidomycosis contagious?
Coccidioidomycosis is not contagious and cannot be transmitted from person to person. It is contracted through inhalation of fungal spores from the environment.
When should I use ICD-10 Code B38.9?
ICD-10 Code B38.9 should be used when the clinical presentation of coccidioidomycosis is not specified, and there is no further detail regarding the type or severity of the infection.
What is the treatment for coccidioidomycosis?
Treatment typically involves antifungal medications such as fluconazole or itraconazole, especially in moderate to severe cases. Supportive care may also be necessary.
