ICD-10 Guide

B38.9

Coccidioidomycosis, unspecified

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/05/2025

Code Description

ICD-10 B38.9 is a billable code used to indicate a diagnosis of coccidioidomycosis, unspecified.

Key Diagnostic Point:

Coccidioidomycosis, commonly known as Valley Fever, is a fungal infection caused by the inhalation of spores from the Coccidioides species, primarily C. immitis and C. posadasii. This infection is endemic to certain regions, particularly the southwestern United States, parts of Mexico, and Central and South America. The disease can manifest in various forms, ranging from asymptomatic to severe pulmonary infections, and can disseminate to other organs, particularly in immunocompromised individuals. Symptoms may include fever, cough, chest pain, fatigue, and in severe cases, can lead to pneumonia or systemic involvement. The unspecified designation indicates that the coder has not specified the severity or location of the infection, which can complicate treatment and management. Antifungal treatments, such as fluconazole or itraconazole, are typically employed, especially in patients with moderate to severe disease or those who are immunocompromised. Accurate coding is essential for appropriate treatment and reimbursement, as well as for tracking epidemiological data related to this infection.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variability in clinical presentation and severity of the disease.
Need for precise documentation of symptoms and treatment response.
Differentiation from other fungal infections and respiratory conditions.
Potential for co-infection in immunocompromised patients.

Audit Risk Factors

Inadequate documentation of clinical findings.
Failure to specify the severity or location of the infection.
Misclassification of the infection type.
Inconsistent treatment documentation, especially for antifungal therapy.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed clinical notes on symptoms, diagnostic tests, and treatment plans.

Common Clinical Scenarios

Patients presenting with respiratory symptoms in endemic areas, or those with a history of travel to endemic regions.

Billing Considerations

Consideration of immunocompromised status and potential for disseminated disease.

Pulmonology

Documentation Requirements

Pulmonary function tests, imaging studies, and response to treatment.

Common Clinical Scenarios

Patients with chronic cough, fever, and chest pain, particularly in endemic areas.

Billing Considerations

Differentiation from other pulmonary infections and conditions.

Coding Guidelines

Inclusion Criteria

Use B38.9 When

Follow the official ICD
CM coding guidelines for infectious diseases, ensuring accurate documentation of the patient's clinical status and any relevant comorbidities
Include additional codes for any complications or associated conditions

Exclusion Criteria

Do NOT use B38.9 When

No specific exclusions found.

Related CPT Codes

87481CPT Code

Coccidioides antibody test

Clinical Scenario

Used to confirm diagnosis in suspected cases.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists should ensure comprehensive testing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of coccidioidomycosis, improving the ability to track and manage this infection in clinical practice.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of coccidioidomycosis, improving the ability to track and manage this infection in clinical practice.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of coccidioidomycosis, improving the ability to track and manage this infection in clinical practice.

Resources

Clinical References

•
CDC Coccidioidomycosis Information

Coding & Billing References

•
CDC Coccidioidomycosis Information

Frequently Asked Questions

What are the common symptoms of coccidioidomycosis?

Common symptoms include fever, cough, chest pain, fatigue, and in severe cases, pneumonia or systemic involvement.

How is coccidioidomycosis treated?

Treatment typically involves antifungal medications such as fluconazole or itraconazole, especially in moderate to severe cases.

ICD-10 B38.9 is a billable code used to indicate a diagnosis of coccidioidomycosis, unspecified.