Toxoplasma chorioretinitis is an ocular manifestation of Toxoplasma gondii infection, primarily affecting the retina and choroid. It is characterized by inflammation that can lead to vision impairment or blindness. Accurate coding with ICD-10 Code B58.01 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.
What is ICD-10 Code B58.01 for Toxoplasma chorioretinitis?
ICD-10 Code B58.01 specifically denotes Toxoplasma chorioretinitis, an inflammatory condition of the eye caused by the Toxoplasma gondii parasite. This code should be used when documenting cases of chorioretinitis linked to Toxoplasma infection, particularly in patients with compromised immune systems or those with a history of exposure to the parasite.
ICD-10 Code B58.01 – Clinical Definition and Explanation of Toxoplasma chorioretinitis
Toxoplasma chorioretinitis is primarily caused by the reactivation of latent Toxoplasma gondii infection, often in immunocompromised individuals. The condition can progress rapidly, leading to significant visual impairment and necessitating prompt medical intervention.
Key Clinical Features:
- Blurred vision or visual disturbances
- Eye pain or discomfort
- Floaters or flashes of light
- Redness and inflammation of the eye
ICD-10 Code B58.01 for Toxoplasma chorioretinitis – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code B58.01 is utilized to document the diagnosis of Toxoplasma chorioretinitis, aiding in the assessment of symptoms, treatment plans, and follow-up care. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code B58.01 for Toxoplasma chorioretinitis Mean in SOAP Notes?
ICD-10 Code B58.01 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Toxoplasma chorioretinitis. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code B58.01 – Toxoplasma chorioretinitis
Toxoplasma chorioretinitis requires urgent medical attention, particularly in immunocompromised patients. Treatment typically involves specific anti-parasitic therapies and supportive care.
Antibiotic Therapy:
- Pyrimethamine and sulfadiazine for 4-6 weeks
- Clindamycin as an alternative for 4-6 weeks
- Trimethoprim-sulfamethoxazole for 4-6 weeks
Supportive Care:
- Corticosteroids to reduce inflammation
- Regular ophthalmologic evaluations
- Patient education on symptom management
Infection Control:
- Educate patients on avoiding exposure to cat feces
- Implement hygiene measures in healthcare settings
- Monitor for outbreaks in immunocompromised populations
How to Document Symptoms of Toxoplasma chorioretinitis (ICD-10 B58.01) in SOAP Notes
Subjective:
- Patient reports blurred vision in one eye
- Complaints of eye pain and discomfort
- History of exposure to cats or undercooked meat
- Noted increase in floaters over the past week
Objective:
- Visual acuity testing shows decreased vision
- Fundoscopic examination reveals retinal lesions
- Intraocular pressure within normal limits
- No signs of systemic infection noted
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SOAP Note Guidelines for Diagnosing Toxoplasma chorioretinitis (ICD-10 Code B58.01)
Assessment:
- Diagnosis of Toxoplasma chorioretinitis, moderate severity
- ICD-10 Code B58.01 confirmed
- Possible triggers include immunosuppression and recent exposure
- Monitor for potential complications such as retinal detachment
Plan:
- Initiate treatment with pyrimethamine and sulfadiazine
- Schedule follow-up ophthalmology appointment in 1 month
- Educate patient on signs of worsening vision
- Consider referral to infectious disease specialist if no improvement
Treatment & Plan Section for ICD-10 Code B58.01 – Toxoplasma chorioretinitis
- First-line treatment includes pyrimethamine and sulfadiazine
- Monitor visual acuity and retinal health regularly
- Educate on lifestyle modifications to reduce exposure risks
- Follow-up care should include reassessment of symptoms and treatment efficacy
Using ICD-10 Code B58.01 for Toxoplasma chorioretinitis in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings
- Use B58.01 in conjunction with relevant CPT codes for billing
- Maintain compliance with coding guidelines to support claims
- Document treatment plans that align with clinical guidelines for reimbursement
Related ICD-10 Codes Often Used with Toxoplasma chorioretinitis
- B58.9 – Toxoplasmosis, unspecified
ICD-10 Code B58.01 in Medical Billing and Insurance for Toxoplasma chorioretinitis
ICD-10 Code B58.01 is critical in the billing process for Toxoplasma chorioretinitis, particularly in hospital and infectious disease settings.
Billing Notes:
- Document all relevant patient history and exposure risks
- Use B58.01 in acute care settings for accurate claims
- Ensure all treatment plans are clearly outlined in the medical record
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 92002 | New patient eye examination, intermediate level |
| 92012 | Established patient eye examination, intermediate level |
| 99203 | New patient office visit, low complexity |
Frequently Asked Questions
Common Questions About Using ICD-10 Code B58.01 for Toxoplasma chorioretinitis
What are the common symptoms of Toxoplasma chorioretinitis?
Common symptoms include blurred vision, eye pain, floaters, and redness. Patients may also experience visual disturbances, which can indicate retinal involvement.
How is Toxoplasma chorioretinitis diagnosed?
Diagnosis typically involves a comprehensive eye examination, including fundoscopic evaluation, and may be supported by serological testing for Toxoplasma antibodies.
What is the treatment for Toxoplasma chorioretinitis?
Treatment usually involves a combination of pyrimethamine and sulfadiazine, along with corticosteroids to manage inflammation. Duration of therapy is typically 4-6 weeks.
Is Toxoplasma chorioretinitis contagious?
Toxoplasma chorioretinitis itself is not contagious; however, the Toxoplasma gondii parasite can be transmitted through contact with infected cat feces or undercooked meat.
