Histoplasmosis duboisii is a fungal infection caused by the organism Histoplasma capsulatum var. duboisii, primarily affecting individuals in certain endemic regions. It can lead to severe pulmonary and systemic manifestations, particularly in immunocompromised patients. Accurate coding with ICD-10 Code B39.5 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage this condition.
What is ICD-10 Code B39.5 for Histoplasmosis duboisii?
ICD-10 Code B39.5 specifically denotes Histoplasmosis duboisii, a variant of histoplasmosis that can cause significant health issues, particularly in immunocompromised individuals. This code should be utilized in clinical documentation and billing when diagnosing patients with this specific fungal infection, ensuring accurate representation of the patient's condition and facilitating appropriate treatment and reimbursement.
ICD-10 Code B39.5 – Clinical Definition and Explanation of Histoplasmosis duboisii
Histoplasmosis duboisii is caused by the fungus Histoplasma capsulatum var. duboisii, which is typically found in certain geographic areas. The infection can progress to severe pulmonary disease and disseminated histoplasmosis, necessitating prompt medical attention. Early diagnosis and treatment are crucial to prevent complications.
Key Clinical Features:
- Chronic cough and chest pain
- Fever and night sweats
- Weight loss and fatigue
- Pulmonary nodules or infiltrates on imaging
ICD-10 Code B39.5 for Histoplasmosis duboisii – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code B39.5 is utilized to document the diagnosis of Histoplasmosis duboisii, 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 B39.5 for Histoplasmosis duboisii Mean in SOAP Notes?
ICD-10 Code B39.5 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Histoplasmosis duboisii. This linkage is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code B39.5 – Histoplasmosis duboisii
Histoplasmosis duboisii may require hospitalization, especially in severe cases. Treatment typically involves antifungal therapy and supportive care.
Antibiotic Therapy:
- Itraconazole (first-line) for 6-12 months
- Amphotericin B (alternative for severe cases)
- Fluconazole (alternative for mild cases)
- Voriconazole (alternative for resistant cases)
Supportive Care:
- Hydration and electrolyte management
- Symptomatic relief for fever and pain
- Monitoring for respiratory distress
- Nutritional support as needed
Infection Control:
- Implement standard precautions
- Isolate immunocompromised patients if necessary
- Educate staff on fungal infection transmission
- Monitor for outbreaks in endemic areas
How to Document Symptoms of Histoplasmosis duboisii (ICD-10 B39.5) in SOAP Notes
Subjective:
- Patient reports persistent cough and chest pain
- History of fever and night sweats
- Notable weight loss over the past month
- Fatigue and malaise reported by the patient
Objective:
- Auscultation reveals crackles in the lungs
- Chest X-ray shows pulmonary nodules
- Vital signs: fever 101°F, respiratory rate 22 breaths/min
- Oxygen saturation at 92% on room air
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SOAP Note Guidelines for Diagnosing Histoplasmosis duboisii (ICD-10 Code B39.5)
Assessment:
- Diagnosis: Histoplasmosis duboisii, moderate severity
- ICD-10 Code: B39.5
- Contributing factors: Immunocompromised status
- Recent travel to endemic region noted.
Plan:
- Initiate itraconazole therapy for 6 months
- Educate patient on medication adherence and side effects
- Schedule follow-up in 4 weeks for reassessment
- Monitor liver function tests during treatment
Treatment & Plan Section for ICD-10 Code B39.5 – Histoplasmosis duboisii
- First-line treatment with itraconazole for moderate cases
- Consider amphotericin B for severe or disseminated disease
- Educate on the importance of follow-up appointments
- Monitor for potential drug interactions and side effects
Using ICD-10 Code B39.5 for Histoplasmosis duboisii in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings
- Use B39.5 in conjunction with relevant CPT codes for billing
- Align treatment plans with clinical guidelines for reimbursement
- Document patient education and follow-up plans clearly
Related ICD-10 Codes Often Used with Histoplasmosis duboisii
- B39.0 – Histoplasmosis, unspecified
- B39.1 – Histoplasmosis, pulmonary
- B39.2 – Histoplasmosis, disseminated
- B39.3 – Histoplasmosis, chronic pulmonary
- B39.4 – Histoplasmosis, acute pulmonary
ICD-10 Code B39.5 in Medical Billing and Insurance for Histoplasmosis duboisii
ICD-10 Code B39.5 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate representation of the patient's condition.
Billing Notes:
- Document all relevant clinical findings to support the diagnosis
- Use B39.5 in appropriate settings to avoid claim denials
- Ensure that treatment plans align with documented symptoms
- Include patient education and follow-up in the medical record
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, level 3 |
| 99285 | Emergency department visit, high severity |
| 36415 | Collection of venous blood by venipuncture |
| 71046 | Chest X-ray, 2 views, frontal and lateral |
Frequently Asked Questions
Common Questions About Using ICD-10 Code B39.5 for Histoplasmosis duboisii
What are the common symptoms of Histoplasmosis duboisii?
Common symptoms include persistent cough, chest pain, fever, night sweats, weight loss, and fatigue. These symptoms may vary in severity and can indicate the need for medical evaluation.
How is Histoplasmosis duboisii diagnosed?
Diagnosis typically involves clinical evaluation, imaging studies such as chest X-rays, and laboratory tests including fungal cultures or serology to confirm the presence of Histoplasma capsulatum var. duboisii.
Is Histoplasmosis duboisii contagious?
Histoplasmosis duboisii is not contagious and is primarily acquired through inhalation of spores from contaminated environments, particularly in endemic areas.
What is the treatment for Histoplasmosis duboisii?
Treatment often includes antifungal medications such as itraconazole or amphotericin B, depending on the severity of the infection. Supportive care may also be necessary for symptom management.
