ICD-10 Code B94.0 | Sequelae of trachoma Symptoms, Diagnosis, Billing

Sequelae of trachoma refers to the long-term effects resulting from a previous trachoma infection, which is caused by the bacterium Chlamydia trachomatis. This condition can lead to complications such as scarring of the conjunctiva and cornea, which may result in visual impairment or blindness. Accurate coding with ICD-10 Code B94.0 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate follow-up care.

What is ICD-10 Code B94.0 for Sequelae of trachoma?

ICD-10 Code B94.0 represents the sequelae of trachoma, which are the chronic complications that arise following an initial trachoma infection. This code should be used when documenting the long-term effects of trachoma, such as scarring and visual impairment, in clinical settings and billing processes. It is crucial for capturing the patient's history of trachoma and ensuring appropriate management of sequelae.

ICD-10 Code B94.0 – Clinical Definition and Explanation of Sequelae of trachoma

Sequelae of trachoma occur as a result of untreated or inadequately treated trachoma, leading to chronic ocular complications. The condition progresses from inflammation to scarring, which can severely impact vision. Medical attention is necessary to manage symptoms and prevent further deterioration.

Key Clinical Features:

• Chronic conjunctival scarring
• Corneal opacification
• Visual impairment or blindness
• Increased risk of secondary infections

ICD-10 Code B94.0 for Sequelae of trachoma – SOAP Notes & Clinical Use

ICD-10 Code B94.0 is utilized in SOAP notes to document the sequelae of trachoma, aiding in the assessment of ongoing symptoms and treatment efficacy. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code B94.0 for Sequelae of trachoma Mean in SOAP Notes?

In SOAP notes, ICD-10 Code B94.0 connects subjective patient reports of symptoms with objective clinical findings, facilitating a formal diagnosis. This code is vital for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code B94.0 – Sequelae of trachoma

Management of sequelae of trachoma requires a multifaceted approach, including medical and supportive therapies to address complications.

Antibiotic Therapy:

• Azithromycin 1g orally as a single dose
• Doxycycline 100mg orally twice daily for 7 days
• Tetracycline ointment applied topically

Supportive Care:

• Regular ophthalmologic evaluations
• Use of artificial tears to alleviate dryness
• Surgical intervention for severe scarring or cataracts

Infection Control:

• Educating patients on hygiene practices
• Screening and treating close contacts
• Monitoring for outbreaks in endemic areas

How to Document Symptoms of Sequelae of trachoma (ICD-10 B94.0) in SOAP Notes

Subjective:

• Patient reports persistent eye irritation and discomfort.
• History of recurrent trachoma infections.
• Complaints of blurred vision and light sensitivity.
• Patient describes difficulty in performing daily activities due to vision issues.

Objective:

• Conjunctival scarring observed on examination.
• Corneal opacification noted during slit-lamp examination.
• Visual acuity measured at 20/200.
• No signs of active infection present.

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SOAP Note Guidelines for Diagnosing Sequelae of trachoma (ICD-10 Code B94.0)

Assessment:

• Diagnosis: Sequelae of trachoma, moderate severity.
• ICD-10 Code: B94.0.
• Contributing factors: History of untreated trachoma.
• Triggers: Environmental irritants and lack of access to clean water.

Plan:

• Initiate antibiotic therapy with azithromycin.
• Schedule follow-up ophthalmology appointment in 3 months.
• Educate patient on eye care and hygiene practices.
• Monitor visual acuity and refer for surgical evaluation if necessary.

Treatment & Plan Section for ICD-10 Code B94.0 – Sequelae of trachoma

• First-line pharmacologic treatment includes azithromycin.
• Non-pharmacologic strategies involve regular eye examinations and hygiene education.
• Monitoring visual acuity and symptoms during follow-up visits.
• Referral for surgical intervention if significant scarring or cataracts develop.

Using ICD-10 Code B94.0 for Sequelae of trachoma in Billing & SOAP Note Compliance

• Select accurate subcodes based on severity of sequelae.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Commonly billed CPT codes include those for ophthalmologic evaluations and procedures.

Related ICD-10 Codes Often Used with Sequelae of trachoma

• A74.9 – Other chlamydial infections

ICD-10 Code B94.0 in Medical Billing and Insurance for Sequelae of trachoma

ICD-10 Code B94.0 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate representation of patient conditions.

Billing Notes:

• Document all relevant patient history and symptoms to support the use of this code.
• Use in conjunction with appropriate CPT codes for comprehensive billing.
• Ensure that documentation reflects the chronic nature of the sequelae.

Common CPT Pairings: