ICD-10 Code B39.3 | Disseminated histoplasmosis capsulati Symptoms, Diagnosis, Billing

Disseminated histoplasmosis capsulati is a systemic fungal infection caused by the organism Histoplasma capsulatum. It primarily affects immunocompromised individuals and can lead to severe complications if not diagnosed and treated promptly. The ICD-10 Code B39.3 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this condition.

What is ICD-10 Code B39.3 for Disseminated histoplasmosis capsulati?

ICD-10 Code B39.3 represents disseminated histoplasmosis capsulati, a severe form of histoplasmosis characterized by the spread of the fungus throughout the body. This code should be used when documenting cases where the infection has progressed beyond the lungs, affecting other organs. Accurate coding is essential for appropriate clinical documentation and billing, particularly in cases involving immunocompromised patients.

ICD-10 Code B39.3 – Clinical Definition and Explanation of Disseminated histoplasmosis capsulati

Disseminated histoplasmosis capsulati occurs when Histoplasma capsulatum spreads from the lungs to other parts of the body, often affecting the liver, spleen, and bone marrow. This condition requires immediate medical attention due to its potential severity and complications.

Key Clinical Features:

• Fever and chills, often with night sweats.
• Weight loss and fatigue due to systemic infection.
• Respiratory symptoms such as cough and chest pain.
• Hematological abnormalities, including anemia and leukopenia.

ICD-10 Code B39.3 for Disseminated histoplasmosis capsulati – SOAP Notes & Clinical Use

ICD-10 Code B39.3 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of disseminated histoplasmosis capsulati. It plays a crucial role in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B39.3 for Disseminated histoplasmosis capsulati Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B39.3 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of disseminated histoplasmosis capsulati. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B39.3 – Disseminated histoplasmosis capsulati

Disseminated histoplasmosis capsulati often necessitates hospitalization for effective management. Treatment typically involves antifungal therapy and supportive care.

Antibiotic Therapy:

• First-line: Amphotericin B (liposomal formulation) for 1-2 weeks, followed by itraconazole for 12 months.
• Alternative: Itraconazole alone for mild cases or in patients unable to tolerate amphotericin B.

Supportive Care:

• Fluid management to prevent dehydration.
• Nutritional support to address weight loss.
• Monitoring and managing complications such as anemia.

Infection Control:

• Implement standard precautions to prevent transmission.
• Educate patients on avoiding exposure to environments with high fungal loads.

How to Document Symptoms of Disseminated histoplasmosis capsulati (ICD-10 B39.3) in SOAP Notes

Subjective:

• Patient reports persistent fever and chills.
• History of weight loss and fatigue over the past month.
• Complaints of cough and chest discomfort.
• Recent travel to endemic areas with potential exposure.

Objective:

• Vital signs: Fever 101°F, tachycardia.
• Physical exam reveals splenomegaly and hepatomegaly.
• Laboratory findings: Anemia and leukopenia.
• Chest X-ray shows pulmonary nodules.

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SOAP Note Guidelines for Diagnosing Disseminated histoplasmosis capsulati (ICD-10 Code B39.3)

Assessment:

• Disseminated histoplasmosis capsulati, severe.
• ICD-10 Code: B39.3.
• Contributing factors: Immunocompromised status.

Plan:

• Initiate treatment with amphotericin B followed by itraconazole.
• Provide education on symptom management and infection control.
• Schedule follow-up in 2 weeks to monitor treatment response.
• Consider hematology consult for anemia management.

Treatment & Plan Section for ICD-10 Code B39.3 – Disseminated histoplasmosis capsulati

• Administer antifungal therapy as per treatment guidelines.
• Encourage nutritional support and hydration.
• Monitor laboratory values for hematological status.
• Schedule regular follow-ups to assess treatment efficacy.

Using ICD-10 Code B39.3 for Disseminated histoplasmosis capsulati in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use B39.3 in settings involving hospitalization or specialty care.
• Align treatment plans with clinical guidelines for justified billing.
• Document all relevant patient history and exposure risks.

Related ICD-10 Codes Often Used with Disseminated histoplasmosis capsulati

• B39.0 – Histoplasmosis, pulmonary
• B39.1 – Histoplasmosis, chronic pulmonary
• B39.2 – Histoplasmosis, localized

ICD-10 Code B39.3 in Medical Billing and Insurance for Disseminated histoplasmosis capsulati

ICD-10 Code B39.3 is critical in medical billing, particularly in hospital, emergency room, or infectious disease settings.

Billing Notes:

• Document all relevant clinical findings to support the use of B39.3.
• Use this code in conjunction with appropriate CPT codes for billing.
• Ensure that the patient's history of exposure is clearly noted in the chart.

Common CPT Pairings: