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v1.0.0
ICD-10 Guide
ICD-10 CodesB39.9

B39.9

Histoplasmosis, unspecified

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

Code Description

ICD-10 B39.9 is a billable code used to indicate a diagnosis of histoplasmosis, unspecified.

Key Diagnostic Point:

Histoplasmosis is a fungal infection caused by the organism Histoplasma capsulatum, which is commonly found in soil enriched with bird or bat droppings. The infection primarily affects the lungs but can disseminate to other organs, particularly in immunocompromised individuals. Symptoms may range from mild respiratory issues to severe pneumonia, and in some cases, it can lead to systemic illness. The unspecified designation indicates that the specific type or severity of histoplasmosis has not been determined. Diagnosis typically involves clinical evaluation, imaging studies, and laboratory tests, including cultures and antigen detection. Treatment often includes antifungal medications such as itraconazole or amphotericin B, especially in severe cases or for patients with weakened immune systems. Given the potential for serious complications, timely diagnosis and appropriate management are crucial.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and severity of histoplasmosis.
  • Need for differential diagnosis with other pulmonary infections.
  • Potential for co-infection in immunocompromised patients.
  • Documentation of exposure history to endemic areas.

Audit Risk Factors

  • Inadequate documentation of clinical findings.
  • Failure to specify immunocompromised status.
  • Misclassification of histoplasmosis severity.
  • Lack of supporting lab results or imaging studies.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed patient history, including exposure risks and clinical symptoms.

Common Clinical Scenarios

Patients presenting with respiratory symptoms and a history of travel to endemic areas.

Billing Considerations

Consideration of immunocompromised status and potential for disseminated disease.

Pulmonology

Documentation Requirements

Pulmonary function tests, imaging results, and treatment response documentation.

Common Clinical Scenarios

Patients with chronic cough, fever, and weight loss.

Billing Considerations

Differentiating from other pulmonary infections and ensuring follow-up care.

Coding Guidelines

Inclusion Criteria

Use B39.9 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the patient's clinical status, exposure history, and any relevant laboratory findings

Exclusion Criteria

Do NOT use B39.9 When
  • Exclude codes for other specific types of histoplasmosis unless clearly documented

Related CPT Codes

87449CPT Code

Infectious agent detection by nucleic acid (DNA or RNA); fungal, direct probe technique

Clinical Scenario

Used when testing for Histoplasma capsulatum in suspected cases.

Documentation Requirements

Document the clinical rationale for testing and any relevant patient history.

Specialty Considerations

Infectious disease specialists should ensure comprehensive documentation of exposure and symptoms.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of histoplasmosis, improving the accuracy of data collection and reimbursement processes. B39.9 serves as a catch-all for unspecified cases, but coders must ensure that documentation supports its use.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of histoplasmosis, improving the accuracy of data collection and reimbursement processes. B39.9 serves as a catch-all for unspecified cases, but coders must ensure that documentation supports its use.

Reimbursement & Billing Impact

reimbursement processes. B39.9 serves as a catch-all for unspecified cases, but coders must ensure that documentation supports its use.

Resources

Clinical References

  • •
    CDC - Histoplasmosis

Coding & Billing References

  • •
    CDC - Histoplasmosis

Frequently Asked Questions

What is the significance of using B39.9?

B39.9 is used when the specific type of histoplasmosis is not documented. It is important to ensure that the clinical context supports its use to avoid audit risks.