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ICD-10 Guide
DiagnosesHistory Of Clostridium Difficile

History Of Clostridium Difficile

ICD-10 Coding for History of Clostridium difficile Infection(A04.71, A04.72, Z86.19)

PRIMARY SPECIALTYInternal Medicine
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is History Of Clostridium Difficile?
Essential facts and insights about History of Clostridium difficile Infection

Key Clinical Considerations:

  • Diarrhea (often watery), abdominal pain, fever, and leukocytosis
  • Nucleic acid amplification tests (NAAT) for toxin genes, enzyme immunoassays (EIAs) for toxins A and B
  • Abdominal tenderness, signs of dehydration, and possible fever

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history of previous C. difficile infections, current symptoms, and treatment history
  • ICD-10-CM coding terminology such as 'History of C. difficile infection' or 'C. difficile colitis'
  • Example: 'Patient has a history of recurrent C. difficile infection treated with antibiotics.'

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for coding history versus active infection; avoid using active infection codes if only history is present.
  • Common errors include misclassifying active infections as history.

Code Exclusions

Important Exclusions

  • Active C. difficile infection codes (A04.7), other gastrointestinal infections
  • Alternative codes for other types of colitis

Related ICD-10 Codes

Primary Codes
Z86.19
Personal history of other infectious and parasitic diseases
Ancillary Codes
Z79.899
Differential Codes
A04.72
A04.71

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Internal Medicine

Specialty Applications

  • Patients with a history of C. difficile infection, particularly those with recurrent episodes
  • Internal medicine, gastroenterology, and infectious disease settings

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Document the patient's history, symptoms, and any previous treatments for C. difficile.

Billing considerations?

Ensure accurate coding to reflect the history of the condition for proper reimbursement.