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v1.0.0
ICD-10 Guide
ICD-10 CodesB58.1

B58.1

Toxoplasma chorioretinitis

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

Code Description

ICD-10 B58.1 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 significant morbidity, particularly in immunocompromised individuals and during pregnancy. 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 an infected mother to her fetus. Diagnosis typically involves clinical examination, serological testing for Toxoplasma antibodies, and imaging studies such as optical coherence tomography (OCT) or fundus photography. Treatment usually includes the use of pyrimethamine and sulfadiazine, along with folinic acid to mitigate the side effects of pyrimethamine. Early diagnosis and treatment are crucial to prevent complications and preserve vision.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acute and chronic cases of chorioretinitis.
  • Need for comprehensive documentation of serological test results.
  • Potential for co-infection with other pathogens in immunocompromised patients.
  • Variability in clinical presentation based on the patient's immune status.

Audit Risk Factors

  • Inadequate documentation of serological test results.
  • Failure to document the patient's immune status.
  • Lack of detailed clinical findings from ophthalmic examinations.
  • Misclassification of the condition as a non-specific chorioretinitis.

Specialty Focus

Medical Specialties

Ophthalmology

Documentation Requirements

Detailed notes on visual acuity, fundoscopic findings, and any imaging results.

Common Clinical Scenarios

Patients presenting with blurred vision, floaters, or acute vision loss.

Billing Considerations

Documentation must clearly indicate the relationship between Toxoplasma infection and ocular symptoms.

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Immunocompromised patients with systemic symptoms and ocular involvement.

Billing Considerations

Need to document any co-infections or underlying conditions affecting the immune system.

Coding Guidelines

Inclusion Criteria

Use B58.1 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, including any relevant laboratory results and clinical findings

Exclusion Criteria

Do NOT use B58.1 When
  • Exclude conditions that do not meet the criteria for Toxoplasma chorioretinitis

Related CPT Codes

92002CPT Code

Ophthalmological examination, new patient

Clinical Scenario

Used when a new patient presents with symptoms suggestive of Toxoplasma chorioretinitis.

Documentation Requirements

Complete eye examination findings and any relevant history.

Specialty Considerations

Ophthalmologists should document specific findings related to Toxoplasma infection.

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 or redness.