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v1.0.0
ICD-10 Guide
ICD-10 CodesB39.4

B39.4

Histoplasmosis capsulati, unspecified

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

Code Description

ICD-10 B39.4 is a billable code used to indicate a diagnosis of histoplasmosis capsulati, unspecified.

Key Diagnostic Point:

Histoplasmosis capsulati is a fungal infection caused by the organism Histoplasma capsulatum, which is commonly found in soil enriched with bird or bat droppings. The infection can manifest in various forms, ranging from asymptomatic to severe pulmonary disease, particularly in immunocompromised individuals. Symptoms may include fever, cough, chest pain, and fatigue. In severe cases, it can disseminate to other organs, leading to systemic complications. Diagnosis typically involves clinical evaluation, imaging studies, and laboratory tests such as culture or antigen detection. Treatment often includes antifungal medications such as itraconazole or amphotericin B, especially in cases of severe disease or in patients with weakened immune systems. The unspecified designation indicates that the specific manifestation or severity of the infection has not been documented, which can complicate treatment decisions and coding accuracy.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and severity of histoplasmosis.
  • Need for precise documentation of symptoms and patient history.
  • Differentiation from other fungal infections and respiratory conditions.
  • Potential for co-morbid conditions in immunocompromised patients.

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings.
  • Failure to specify immunocompromised status.
  • Misclassification of the severity of the infection.
  • Inconsistent use of related codes for co-morbid conditions.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed clinical history, laboratory results, and treatment plans.

Common Clinical Scenarios

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

Billing Considerations

Consideration of immunocompromised status and potential for disseminated disease.

Pulmonology

Documentation Requirements

Pulmonary function tests, imaging studies, and symptom assessment.

Common Clinical Scenarios

Patients with chronic cough and pulmonary nodules.

Billing Considerations

Differentiation from other pulmonary infections and conditions.

Coding Guidelines

Inclusion Criteria

Use B39.4 When
  • Follow ICD
  • CM guidelines for coding fungal infections, ensuring specificity in documentation
  • Include relevant patient history, symptoms, and treatment plans
  • existing

Exclusion Criteria

Do NOT use B39.4 When
  • Exclude codes for other fungal infections unless co

Related CPT Codes

87449CPT Code

Histoplasma antigen test

Clinical Scenario

Used for diagnosis in suspected cases of histoplasmosis.

Documentation Requirements

Document clinical suspicion and test results.

Specialty Considerations

Infectious disease specialists may order this test.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 allows for more specific coding of histoplasmosis, improving data accuracy and treatment tracking. B39.4 provides a clear designation for unspecified cases, aiding in epidemiological studies.

ICD-9 vs ICD-10

The transition to ICD-10 allows for more specific coding of histoplasmosis, improving data accuracy and treatment tracking. B39.4 provides a clear designation for unspecified cases, aiding in epidemiological studies.

Reimbursement & Billing Impact

The transition to ICD-10 allows for more specific coding of histoplasmosis, improving data accuracy and treatment tracking. B39.4 provides a clear designation for unspecified cases, aiding in epidemiological studies.

Resources

Clinical References

  • •
    CDC - Histoplasmosis

Coding & Billing References

  • •
    CDC - Histoplasmosis

Frequently Asked Questions

What are the common symptoms of histoplasmosis?

Common symptoms include fever, cough, chest pain, fatigue, and in severe cases, weight loss and respiratory distress.

How is histoplasmosis diagnosed?

Diagnosis typically involves clinical evaluation, imaging studies, and laboratory tests such as culture or antigen detection.

What is the treatment for histoplasmosis?

Treatment often includes antifungal medications such as itraconazole or amphotericin B, especially in severe cases or in immunocompromised patients.