ICD-10 Code B48.4 | Penicillosis Symptoms, Diagnosis, Billing

Penicillosis is a fungal infection caused by the Penicillium species, primarily affecting immunocompromised individuals. It can lead to significant morbidity if not diagnosed and treated promptly. The ICD-10 Code B48.4 facilitates accurate diagnosis, documentation, and billing, ensuring proper management and reporting of this condition in healthcare settings.

What is ICD-10 Code B48.4 for Penicillosis?

ICD-10 Code B48.4 represents Penicillosis, a fungal infection caused by the Penicillium species. This code is used when documenting cases of Penicillosis in clinical settings, particularly in patients with weakened immune systems. Accurate coding is essential for appropriate treatment, billing, and epidemiological tracking.

ICD-10 Code B48.4 – Clinical Definition and Explanation of Penicillosis

Penicillosis is primarily caused by exposure to the Penicillium fungus, which can lead to respiratory and systemic infections, particularly in immunocompromised patients. Early recognition and treatment are crucial to prevent complications and improve patient outcomes.

Key Clinical Features:

• Commonly presents with respiratory symptoms such as cough and dyspnea.
• Can cause systemic symptoms including fever and malaise.
• More prevalent in immunocompromised individuals, such as those with HIV/AIDS or undergoing chemotherapy.
• Diagnosis often confirmed through culture or histopathological examination.

ICD-10 Code B48.4 for Penicillosis – SOAP Notes & Clinical Use

ICD-10 Code B48.4 is utilized in SOAP notes to document the presence of Penicillosis, 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 B48.4 for Penicillosis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B48.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Penicillosis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B48.4 – Penicillosis

Prompt treatment of Penicillosis is essential, particularly in immunocompromised patients. Hospitalization may be required for severe cases.

Antibiotic Therapy:

• First-line: Voriconazole or Itraconazole for 6-12 weeks.
• Alternative: Amphotericin B for severe infections.

Supportive Care:

• Monitor vital signs and respiratory status.
• Provide supplemental oxygen if needed.
• Manage fever and pain with appropriate medications.

Infection Control:

• Implement standard precautions to prevent transmission.
• Isolate patients with severe infections if necessary.
• Educate staff on handling fungal infections.

How to Document Symptoms of Penicillosis (ICD-10 B48.4) in SOAP Notes

Subjective:

• Patient reports persistent cough and shortness of breath.
• History of immunosuppression due to recent chemotherapy.
• Complaints of fever and fatigue over the past week.

Objective:

• Auscultation reveals bilateral crackles.
• Temperature: 101°F, Respiratory rate: 22 breaths/min.
• Chest X-ray shows infiltrates consistent with fungal infection.

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SOAP Note Guidelines for Diagnosing Penicillosis (ICD-10 Code B48.4)

Assessment:

• Diagnosis: Penicillosis, moderate severity.
• ICD-10 Code: B48.4.
• Contributing factors: Immunocompromised state due to chemotherapy.

Plan:

• Initiate treatment with Voriconazole.
• Educate patient on signs of worsening symptoms.
• Schedule follow-up in one week to assess treatment response.

Treatment & Plan Section for ICD-10 Code B48.4 – Penicillosis

• First-line pharmacologic treatment: Voriconazole.
• Non-pharmacologic strategies: Ensure adequate hydration and nutrition.
• Monitoring: Regular follow-up appointments to assess treatment efficacy.
• Follow-up practices: Chest imaging to monitor resolution of infiltrates.

Using ICD-10 Code B48.4 for Penicillosis in Billing & SOAP Note Compliance

• Select accurate subcodes based on clinical severity or complications.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Only list CPT codes that are commonly billed with ICD-10 Code B48.4 based on standard medical coding practices.

Related ICD-10 Codes Often Used with Penicillosis

• B44.9 – Aspergillosis, unspecified
• B49 – Unspecified mycosis
• B37.9 – Candidiasis, unspecified

ICD-10 Code B48.4 in Medical Billing and Insurance for Penicillosis

ICD-10 Code B48.4 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure accurate documentation of symptoms and treatment to support claims.
• Use this code in inpatient and outpatient settings for appropriate reimbursement.
• Include relevant clinical findings in the medical record to justify the diagnosis.

Common CPT Pairings: