ICD-10 Code B58.9 | Toxoplasmosis, unspecified Symptoms, Diagnosis, Billing

Toxoplasmosis, unspecified is an infection caused by the parasite Toxoplasma gondii. It can lead to serious health complications, particularly in immunocompromised individuals and pregnant women. Accurate coding with ICD-10 Code B58.9 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 B58.9 for Toxoplasmosis, unspecified?

ICD-10 Code B58.9 represents Toxoplasmosis, unspecified, indicating a diagnosis of Toxoplasma gondii infection without further specification of the clinical manifestation. This code is used when the condition is identified but lacks detailed classification, facilitating appropriate clinical documentation and billing in various healthcare settings.

ICD-10 Code B58.9 – Clinical Definition and Explanation of Toxoplasmosis, unspecified

Toxoplasmosis is primarily caused by the ingestion of oocysts from contaminated food, water, or soil, or through contact with infected cats. The condition can progress asymptomatically or lead to severe complications, particularly in immunocompromised patients and during pregnancy, necessitating medical intervention.

Key Clinical Features:

• Asymptomatic in many cases, but can cause flu-like symptoms.
• Severe complications in immunocompromised individuals, such as encephalitis.
• Potential congenital transmission leading to serious fetal outcomes.
• Diagnosis often confirmed through serological testing.

ICD-10 Code B58.9 for Toxoplasmosis, unspecified – SOAP Notes & Clinical Use

ICD-10 Code B58.9 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans related to Toxoplasmosis, unspecified. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B58.9 for Toxoplasmosis, unspecified Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B58.9 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Toxoplasmosis, unspecified. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code B58.9 – Toxoplasmosis, unspecified

Toxoplasmosis may require hospitalization, especially in severe cases. Treatment typically involves specific medications and supportive care to manage symptoms and prevent complications.

Antibiotic Therapy:

• Pyrimethamine and sulfadiazine for acute treatment, typically for 4-6 weeks.
• Clindamycin as an alternative for those allergic to sulfa drugs.
• Spiramycin for pregnant women to reduce fetal transmission.

Supportive Care:

• Hydration and nutritional support as needed.
• Management of symptoms such as fever and pain.
• Monitoring for complications in immunocompromised patients.

Infection Control:

• Educating patients on hygiene practices to prevent transmission.
• Avoiding contact with cat feces and contaminated soil.
• Implementing precautions in healthcare settings during outbreaks.

How to Document Symptoms of Toxoplasmosis, unspecified (ICD-10 B58.9) in SOAP Notes

Subjective:

• Patient reports flu-like symptoms including fatigue and mild fever.
• History of exposure to cat litter or undercooked meat.
• Recent travel to areas with high prevalence of Toxoplasmosis.

Objective:

• Vital signs: Temperature 100.4°F, pulse 78 bpm.
• Physical examination reveals lymphadenopathy.
• Serological tests show positive IgG and IgM for Toxoplasma.

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SOAP Note Guidelines for Diagnosing Toxoplasmosis, unspecified (ICD-10 Code B58.9)

Assessment:

• Diagnosis: Toxoplasmosis, unspecified, moderate severity.
• ICD-10 Code: B58.9.
• Contributing factors: Recent exposure to potential sources of infection.

Plan:

• Initiate treatment with pyrimethamine and sulfadiazine.
• Educate patient on hygiene and prevention strategies.
• Schedule follow-up in 2 weeks to monitor treatment response.

Treatment & Plan Section for ICD-10 Code B58.9 – Toxoplasmosis, unspecified

• First-line treatment includes pyrimethamine and sulfadiazine.
• Consider clindamycin for patients with sulfa allergies.
• Monitor for side effects and treatment efficacy.
• Provide education on prevention and symptom management.

Using ICD-10 Code B58.9 for Toxoplasmosis, unspecified in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use B58.9 in settings where Toxoplasmosis is diagnosed but not specified.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Toxoplasmosis, unspecified

• B58.1 – Toxoplasmosis, congenital
• B58.9 – Toxoplasmosis, unspecified

ICD-10 Code B58.9 in Medical Billing and Insurance for Toxoplasmosis, unspecified

ICD-10 Code B58.9 is crucial for billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Document all relevant patient history and exposure risks.
• Use B58.9 in cases where Toxoplasmosis is diagnosed but lacks specificity.
• Ensure that all chart elements support the claim for reimbursement.

Common CPT Pairings: