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ICD-10 Guide
ICD-10 CodesB16.1

B16.1

Acute hepatitis B with delta-agent infection

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

Code Description

ICD-10 B16.1 is a billable code used to indicate a diagnosis of acute hepatitis b with delta-agent infection.

Key Diagnostic Point:

Acute hepatitis B with delta-agent infection is a viral infection of the liver caused by the hepatitis B virus (HBV) in conjunction with the hepatitis D virus (HDV), also known as the delta agent. This condition occurs when a person is simultaneously infected with both HBV and HDV, leading to a more severe form of hepatitis. The delta agent requires the presence of HBV to replicate, making co-infection particularly concerning. Symptoms may include jaundice, fatigue, abdominal pain, and elevated liver enzymes. Acute hepatitis B can progress to chronic infection, especially in individuals with compromised immune systems. The transmission routes primarily include percutaneous exposure to infected blood, sexual contact, and from mother to child during childbirth. Management of acute hepatitis B with delta-agent infection focuses on supportive care, monitoring liver function, and preventing complications such as liver failure or cirrhosis. Chronic management may involve antiviral therapy and regular surveillance for liver disease progression.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Co-infection with two viruses complicates diagnosis and treatment.
  • Differentiating between acute and chronic hepatitis B can be challenging.
  • Requires comprehensive documentation of both HBV and HDV infections.
  • Potential for severe liver complications necessitates careful monitoring.

Audit Risk Factors

  • Inadequate documentation of both HBV and HDV infections.
  • Failure to document the severity of liver disease.
  • Misclassification of acute versus chronic hepatitis.
  • Lack of follow-up documentation for chronic management.

Specialty Focus

Medical Specialties

Gastroenterology

Documentation Requirements

Detailed history of liver function tests, imaging studies, and treatment plans.

Common Clinical Scenarios

Patients presenting with jaundice, elevated liver enzymes, or acute liver failure.

Billing Considerations

Ensure documentation reflects the dual infection and any complications.

Infectious Disease

Documentation Requirements

Comprehensive history of exposure, serological testing results, and treatment response.

Common Clinical Scenarios

Patients with recent travel history or high-risk behaviors presenting with hepatitis symptoms.

Billing Considerations

Document any co-morbid conditions that may affect treatment outcomes.

Coding Guidelines

Inclusion Criteria

Use B16.1 When
  • According to ICD
  • 10 guidelines, B16
  • 1 should be used when both HBV and HDV infections are confirmed
  • Documentation must support the diagnosis, including serological tests and clinical findings
  • infection

Exclusion Criteria

Do NOT use B16.1 When
  • Exclusion criteria include cases where only HBV or HDV is present without co

Related CPT Codes

86803CPT Code

Hepatitis B surface antigen (HBsAg) test

Clinical Scenario

Used to confirm the presence of HBV in patients suspected of hepatitis.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Gastroenterology may require additional liver function tests.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hepatitis infections, including the differentiation between acute and chronic forms, as well as co-infections like HBV and HDV. This specificity improves data accuracy and enhances patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hepatitis infections, including the differentiation between acute and chronic forms, as well as co-infections like HBV and HDV. This specificity improves data accuracy and enhances patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of hepatitis infections, including the differentiation between acute and chronic forms, as well as co-infections like HBV and HDV. This specificity improves data accuracy and enhances patient management.

Resources

Clinical References

  • •
    CDC Hepatitis B Information

Coding & Billing References

  • •
    CDC Hepatitis B Information

Frequently Asked Questions

What are the symptoms of acute hepatitis B with delta-agent infection?

Symptoms may include jaundice, fatigue, abdominal pain, nausea, and elevated liver enzymes. Some patients may be asymptomatic.

How is acute hepatitis B with delta-agent infection diagnosed?

Diagnosis is made through serological testing for HBsAg and anti-HDV antibodies, along with clinical evaluation.

What is the treatment for acute hepatitis B with delta-agent infection?

Treatment is primarily supportive, focusing on monitoring liver function and managing symptoms. Antiviral therapy may be considered in severe cases.