Proteus (mirabilis) and Proteus (morganii) are gram-negative bacteria that can cause infections in various body systems. The ICD-10 code B96.4 is used to identify these specific pathogens as the cause of diseases classified elsewhere. Accurate coding with B96.4 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage infections effectively.
What is ICD-10 Code B96.4 for Proteus (mirabilis) (morganii) causing dis classd elswhr?
ICD-10 Code B96.4 represents infections caused by Proteus (mirabilis) and Proteus (morganii) that are classified elsewhere in the ICD-10 system. This code is applicable when these bacteria are identified as the causative agents of infections in various anatomical sites, such as urinary tract infections or wound infections. It should be used in clinical documentation and billing when these pathogens are confirmed as the underlying cause of a patient's condition.
ICD-10 Code B96.4 – Clinical Definition and Explanation of Proteus (mirabilis) (morganii) causing dis classd elswhr
Proteus (mirabilis) and Proteus (morganii) are opportunistic pathogens commonly associated with urinary tract infections and other infections in immunocompromised patients. These bacteria can lead to serious complications if not promptly addressed, necessitating accurate diagnosis and treatment.
Key Clinical Features:
- Commonly associated with urinary tract infections, particularly in patients with urinary catheters.
- Can cause wound infections, especially in surgical patients or those with compromised skin integrity.
- Known for producing urease, which can lead to struvite stone formation in the urinary tract.
- May present with symptoms such as fever, dysuria, and flank pain.
ICD-10 Code B96.4 for Proteus (mirabilis) (morganii) causing dis classd elswhr – SOAP Notes & Clinical Use
ICD-10 Code B96.4 is utilized in SOAP notes to document the presence of Proteus (mirabilis) or Proteus (morganii) as the causative agent of infections. This code aids in the assessment of symptoms, guiding treatment decisions and ensuring accurate billing in both acute and chronic care settings.
What Does ICD-10 Code B96.4 for Proteus (mirabilis) (morganii) causing dis classd elswhr Mean in SOAP Notes?
In SOAP notes, ICD-10 Code B96.4 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of infection caused by Proteus species. This code is crucial for ensuring continuity of care, supporting appropriate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code B96.4 – Proteus (mirabilis) (morganii) causing dis classd elswhr
Prompt treatment of infections caused by Proteus (mirabilis) and Proteus (morganii) is essential to prevent complications. Antibiotic therapy is typically guided by culture and sensitivity results.
Antibiotic Therapy:
- First-line: Ciprofloxacin or Levofloxacin for uncomplicated infections, typically for 7-14 days.
- Alternative: Trimethoprim-sulfamethoxazole if sensitivity is confirmed.
- Consideration of intravenous antibiotics for severe infections or in hospitalized patients.
Supportive Care:
- Hydration to support renal function and flush urinary tract.
- Pain management with analgesics as needed.
- Monitoring for signs of systemic infection or sepsis.
Infection Control:
- Strict hand hygiene practices to prevent transmission.
- Isolation precautions for patients with multidrug-resistant strains.
- Education on proper catheter care for patients with urinary catheters.
How to Document Symptoms of Proteus (mirabilis) (morganii) causing dis classd elswhr (ICD-10 B96.4) in SOAP Notes
Subjective:
- Patient reports dysuria and increased urinary frequency.
- History of recurrent urinary tract infections.
- Complaints of flank pain and fever over the past 48 hours.
Objective:
- Vital signs: Temperature 101°F, heart rate 90 bpm.
- Urinalysis shows leukocyte esterase and nitrites.
- Physical exam reveals tenderness in the suprapubic area.
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SOAP Note Guidelines for Diagnosing Proteus (mirabilis) (morganii) causing dis classd elswhr (ICD-10 Code B96.4)
Assessment:
- Diagnosis: Urinary tract infection due to Proteus (mirabilis), moderate severity.
- ICD-10 Code: B96.4.
- Contributing factors: Recent catheterization and history of UTIs.
Plan:
- Initiate antibiotic therapy with Ciprofloxacin for 10 days.
- Educate patient on hydration and signs of worsening infection.
- Schedule follow-up in one week to reassess symptoms.
Treatment & Plan Section for ICD-10 Code B96.4 – Proteus (mirabilis) (morganii) causing dis classd elswhr
- First-line pharmacologic treatment includes Ciprofloxacin or Levofloxacin.
- Non-pharmacologic strategies involve increasing fluid intake and proper hygiene.
- Monitoring includes follow-up urinalysis to confirm resolution of infection.
- Patient education on recognizing symptoms of recurrent infections.
Using ICD-10 Code B96.4 for Proteus (mirabilis) (morganii) causing dis classd elswhr in Billing & SOAP Note Compliance
- Select appropriate subcodes based on the severity of the infection.
- 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 urinalysis and office visits.
Related ICD-10 Codes Often Used with Proteus (mirabilis) (morganii) causing dis classd elswhr
- A49.9 – Bacterial infection, unspecified
ICD-10 Code B96.4 in Medical Billing and Insurance for Proteus (mirabilis) (morganii) causing dis classd elswhr
ICD-10 Code B96.4 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.
Billing Notes:
- Ensure documentation includes specific symptoms and laboratory findings to support the diagnosis.
- Use B96.4 in conjunction with other relevant codes for comprehensive billing.
- Document the treatment plan and follow-up care to justify the medical necessity.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 87086 | Culture, bacterial, any source, with isolation and identification. |
| 99213 | Office or other outpatient visit for evaluation and management. |
| 81002 | Urinalysis, automated, with microscopy. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code B96.4 for Proteus (mirabilis) (morganii) causing dis classd elswhr
What are the common symptoms of a Proteus infection?
Common symptoms include dysuria, increased urinary frequency, flank pain, and fever. Patients may also experience malaise and changes in urine appearance.
How is a Proteus infection diagnosed?
Diagnosis typically involves urinalysis and urine culture to identify the presence of Proteus species. Imaging may be necessary for complicated cases.
What is the treatment for a Proteus infection?
Treatment usually involves antibiotics such as Ciprofloxacin or Levofloxacin, guided by culture sensitivity. Supportive care and hydration are also important.
When should ICD-10 Code B96.4 be used?
This code should be used when Proteus (mirabilis) or Proteus (morganii) is identified as the causative agent of an infection classified elsewhere in the ICD-10 system.
