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v1.0.0
ICD-10 Guide
ICD-10 CodesB16.9

B16.9

Acute hepatitis B without delta-agent and without hepatic coma

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 B16.9 is a billable code used to indicate a diagnosis of acute hepatitis b without delta-agent and without hepatic coma.

Key Diagnostic Point:

Acute hepatitis B is a viral infection of the liver caused by the hepatitis B virus (HBV). It is characterized by the sudden onset of symptoms such as jaundice, fatigue, abdominal pain, and elevated liver enzymes. The infection is primarily transmitted through contact with infectious body fluids, including blood, semen, and vaginal secretions. Acute hepatitis B can lead to serious liver complications, including acute liver failure, and can progress to chronic hepatitis B in some individuals. The absence of delta-agent indicates that the infection is not compounded by the presence of the hepatitis D virus, which can worsen the disease. Patients with acute hepatitis B typically recover fully, but monitoring for complications and liver function is essential. Management includes supportive care, and in some cases, antiviral therapy may be indicated. The prognosis is generally favorable, but chronic infection can develop in a subset of patients, necessitating long-term monitoring and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acute and chronic hepatitis B
  • Understanding transmission routes and risk factors
  • Identifying complications and co-infections
  • Documentation of symptoms and laboratory findings

Audit Risk Factors

  • Inadequate documentation of symptoms and laboratory results
  • Misclassification of acute versus chronic hepatitis
  • Failure to document risk factors for transmission
  • Inconsistent coding of related liver conditions

Specialty Focus

Medical Specialties

Gastroenterology

Documentation Requirements

Detailed history of present illness, laboratory results, and imaging studies.

Common Clinical Scenarios

Patients presenting with jaundice, elevated liver enzymes, and abdominal pain.

Billing Considerations

Ensure documentation reflects the acute nature of the condition and any complications.

Infectious Disease

Documentation Requirements

History of exposure, serological testing results, and treatment plans.

Common Clinical Scenarios

Patients with recent travel history or high-risk behaviors presenting with hepatitis symptoms.

Billing Considerations

Documenting risk factors for transmission and potential co-infections.

Coding Guidelines

Inclusion Criteria

Use B16.9 When
  • Follow ICD
  • CM guidelines for coding hepatitis B, ensuring accurate documentation of acute versus chronic conditions
  • Include relevant laboratory findings and symptoms in the medical record

Exclusion Criteria

Do NOT use B16.9 When
No specific exclusions found.

Related CPT Codes

86704CPT Code

Hepatitis B surface antigen (HBsAg) test

Clinical Scenario

Used to confirm diagnosis of acute hepatitis B.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Gastroenterology and Infectious Disease specialists should ensure comprehensive documentation.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hepatitis B, improving the accuracy of data collection and management of the disease. B16.9 provides a clear distinction for acute cases without complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hepatitis B, improving the accuracy of data collection and management of the disease. B16.9 provides a clear distinction for acute cases without complications.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of hepatitis B, improving the accuracy of data collection and management of the disease. B16.9 provides a clear distinction for acute cases without complications.

Resources

Clinical References

  • •
    CDC Hepatitis B Information

Coding & Billing References

  • •
    CDC Hepatitis B Information

Frequently Asked Questions

What are the common symptoms of acute hepatitis B?

Common symptoms include jaundice, fatigue, abdominal pain, nausea, and loss of appetite. Some individuals may be asymptomatic.

How is acute hepatitis B transmitted?

Acute hepatitis B is primarily transmitted through contact with infectious body fluids, including blood, semen, and vaginal secretions.

What is the prognosis for acute hepatitis B?

Most adults recover completely from acute hepatitis B, but a small percentage may develop chronic infection, which requires ongoing management.

What laboratory tests are used to diagnose acute hepatitis B?

Diagnosis is confirmed through serological testing for hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc).