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ICD-10 Guide
ICD-10 CodesB57.4

B57.4

Toxoplasma chorioretinitis

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

Code Description

ICD-10 B57.4 is a billable code used to indicate a diagnosis of toxoplasma chorioretinitis.

Key Diagnostic Point:

Toxoplasma chorioretinitis is an ocular manifestation of Toxoplasma gondii infection, a protozoan parasite that can cause severe complications in immunocompromised individuals, particularly those with HIV/AIDS. The condition is characterized by inflammation of the choroid and retina, leading to symptoms such as blurred vision, floaters, and in severe cases, vision loss. Toxoplasmosis is often acquired through ingestion of oocysts from contaminated food or water, or through vertical transmission from mother to fetus during pregnancy. Diagnosis typically involves clinical examination, serological testing for Toxoplasma antibodies, and imaging studies such as fundus photography or optical coherence tomography. Treatment usually includes the use of pyrimethamine and sulfadiazine, along with leucovorin to mitigate bone marrow suppression. Early diagnosis and treatment are crucial to prevent irreversible damage to the retina and preserve vision.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from other causes of chorioretinitis
  • Need for serological confirmation of Toxoplasma infection
  • Potential for co-infection with other pathogens
  • Variability in clinical presentation based on immune status

Audit Risk Factors

  • Inadequate documentation of serological test results
  • Failure to document the patient's immune status
  • Lack of clarity in the clinical presentation
  • Improper linkage of diagnosis to treatment provided

Specialty Focus

Medical Specialties

Ophthalmology

Documentation Requirements

Detailed ocular examination findings, including visual acuity and fundoscopic findings.

Common Clinical Scenarios

Patients presenting with blurred vision and floaters, particularly in immunocompromised individuals.

Billing Considerations

Ensure documentation reflects the severity of the condition and any associated systemic symptoms.

Infectious Disease

Documentation Requirements

Comprehensive history of exposure, serological test results, and treatment plans.

Common Clinical Scenarios

Patients with HIV/AIDS presenting with ocular symptoms and a history of Toxoplasma exposure.

Billing Considerations

Document any co-infections and the patient's immune status to support the diagnosis.

Coding Guidelines

Inclusion Criteria

Use B57.4 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, treatment, and any related conditions
  • Include specific details about the patient's immune status and any serological testing performed

Exclusion Criteria

Do NOT use B57.4 When
No specific exclusions found.

Related CPT Codes

92002CPT Code

Ophthalmological examination, new patient

Clinical Scenario

Used during initial evaluation of a patient suspected of having Toxoplasma chorioretinitis.

Documentation Requirements

Document visual acuity, fundoscopic findings, and any relevant history.

Specialty Considerations

Ophthalmologists should ensure comprehensive documentation of ocular findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of Toxoplasma-related conditions, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of Toxoplasma-related conditions, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    CDC Toxoplasmosis Information

Coding & Billing References

  • •
    CDC Toxoplasmosis Information

Frequently Asked Questions

What are the common symptoms of Toxoplasma chorioretinitis?

Common symptoms include blurred vision, floaters, and in severe cases, vision loss. Patients may also experience eye pain and redness.