Histoplasmosis capsulati, unspecified is a fungal infection caused by the organism Histoplasma capsulatum. It primarily affects the lungs but can disseminate to other organs. Accurate coding with ICD-10 Code B39.4 is essential for proper diagnosis, documentation, and billing, ensuring appropriate treatment and public health reporting.
What is ICD-10 Code B39.4 for Histoplasmosis capsulati, unspecified?
ICD-10 Code B39.4 represents Histoplasmosis capsulati, unspecified, a fungal infection that may present with respiratory symptoms or systemic manifestations. This code is used when the specific type of histoplasmosis is not identified, facilitating accurate clinical documentation and billing for healthcare services related to this condition.
ICD-10 Code B39.4 – Clinical Definition and Explanation of Histoplasmosis capsulati, unspecified
Histoplasmosis capsulati, unspecified is caused by inhaling spores of the fungus Histoplasma capsulatum, commonly found in soil enriched with bird or bat droppings. The condition can progress from mild respiratory illness to severe systemic disease, necessitating medical intervention.
Key Clinical Features:
- Fever and chills
- Cough and chest pain
- Fatigue and malaise
- Weight loss and night sweats
ICD-10 Code B39.4 for Histoplasmosis capsulati, unspecified – SOAP Notes & Clinical Use
ICD-10 Code B39.4 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and guiding clinical decision-making.
What Does ICD-10 Code B39.4 for Histoplasmosis capsulati, unspecified Mean in SOAP Notes?
In SOAP notes, ICD-10 Code B39.4 connects subjective patient-reported symptoms with objective clinical findings, facilitating a formal diagnosis. This code supports continuity of care, aids in billing processes, and meets EHR documentation standards.
Treatment Options for ICD-10 Code B39.4 – Histoplasmosis capsulati, unspecified
Histoplasmosis capsulati, unspecified may require hospitalization, especially in severe cases. Treatment typically involves antifungal therapy and supportive care.
Antibiotic Therapy:
- Itraconazole (first-line) for 6-12 weeks
- Fluconazole (alternative) for 6-12 weeks
- Amphotericin B for severe cases
- Voriconazole (alternative) for resistant cases
Supportive Care:
- Hydration and electrolyte management
- Oxygen therapy for respiratory distress
- Symptomatic treatment for fever and pain
- Nutritional support as needed
Infection Control:
- Implement standard precautions
- Educate on avoiding exposure to contaminated environments
- Monitor for outbreaks in endemic areas
- Report cases to public health authorities
How to Document Symptoms of Histoplasmosis capsulati, unspecified (ICD-10 B39.4) in SOAP Notes
Subjective:
- Patient reports persistent cough for 2 weeks
- Experiencing fever and chills intermittently
- Notable weight loss of 10 pounds in the last month
- History of exposure to bird droppings
Objective:
- Auscultation reveals crackles in the lungs
- Vital signs: Temp 101°F, HR 90 bpm, RR 20
- Chest X-ray shows infiltrates
- Oxygen saturation at 92% on room air
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SOAP Note Guidelines for Diagnosing Histoplasmosis capsulati, unspecified (ICD-10 Code B39.4)
Assessment:
- Diagnosis: Histoplasmosis capsulati, unspecified, moderate severity
- ICD-10 Code: B39.4
- Contributing factors: Recent travel to endemic area
- Possible exposure to contaminated soil
Plan:
- Initiate itraconazole therapy for 6-12 weeks
- Educate patient on medication adherence and side effects
- Schedule follow-up in 4 weeks to monitor progress
- Consider referral to infectious disease specialist if no improvement
Treatment & Plan Section for ICD-10 Code B39.4 – Histoplasmosis capsulati, unspecified
- First-line treatment with itraconazole or amphotericin B for severe cases
- Educate on avoiding exposure to potential sources of infection
- Monitor symptoms and adjust treatment as necessary
- Follow-up appointments to assess treatment efficacy and side effects
Using ICD-10 Code B39.4 for Histoplasmosis capsulati, unspecified in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings
- Use B39.4 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 Histoplasmosis capsulati, unspecified
- B39.0 – Histoplasmosis capsulati, pulmonary
- B39.1 – Histoplasmosis capsulati, disseminated
- B39.2 – Histoplasmosis capsulati, chronic pulmonary
- B39.3 – Histoplasmosis capsulati, acute pulmonary
ICD-10 Code B39.4 in Medical Billing and Insurance for Histoplasmosis capsulati, unspecified
ICD-10 Code B39.4 is crucial for billing in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant clinical findings to support the diagnosis
- Use B39.4 in appropriate clinical settings to ensure proper reimbursement
- Include detailed treatment plans in the medical record
- Ensure compliance with payer-specific documentation requirements
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, level 3 |
| 71046 | Chest X-ray, two views |
| 36415 | Collection of venous blood by venipuncture |
| 99232 | Subsequent hospital care, level 2 |
Frequently Asked Questions
Common Questions About Using ICD-10 Code B39.4 for Histoplasmosis capsulati, unspecified
What are the common symptoms of Histoplasmosis capsulati?
Common symptoms include fever, cough, chest pain, fatigue, and weight loss. Patients may also experience night sweats and chills, particularly in more severe cases.
How is Histoplasmosis capsulati diagnosed?
Diagnosis typically involves clinical evaluation, imaging studies such as chest X-rays, and laboratory tests including fungal cultures or antigen detection from serum or urine.
Is Histoplasmosis capsulati contagious?
Histoplasmosis capsulati is not contagious and is primarily contracted through inhalation of spores from contaminated environments, particularly soil enriched with bird or bat droppings.
What is the treatment for Histoplasmosis capsulati?
Treatment often includes antifungal medications such as itraconazole or amphotericin B for severe cases. Supportive care may also be necessary to manage symptoms.
