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ICD-10 Guide
ICD-10 CodesB57.2

B57.2

Toxoplasma chorioretinitis

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

Code Description

ICD-10 B57.2 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. The infection is often acquired through ingestion of oocysts found in contaminated food or water, or through contact with infected cat feces. In immunocompetent individuals, Toxoplasma chorioretinitis may remain asymptomatic or present with mild symptoms, but in those with weakened immune systems, such as HIV/AIDS patients, it can lead to severe ocular complications. Diagnosis typically involves clinical examination, serological testing for Toxoplasma antibodies, and imaging studies such as fundus photography or OCT (optical coherence tomography). Treatment usually includes antiparasitic medications such as pyrimethamine and sulfadiazine, often combined with corticosteroids to reduce inflammation. 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

  • Differentiating between acute and chronic cases of chorioretinitis.
  • Understanding the immunocompromised status of the patient.
  • Knowledge of associated systemic conditions (e.g., HIV/AIDS).
  • Awareness of potential complications and their documentation.

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings.
  • Failure to specify the immunocompromised status of the patient.
  • Lack of clarity in distinguishing between acute and chronic conditions.
  • Insufficient detail on treatment protocols and follow-up care.

Specialty Focus

Medical Specialties

Ophthalmology

Documentation Requirements

Detailed ocular examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with vision changes, floaters, or diagnosed with Toxoplasma infection.

Billing Considerations

Documentation must clearly indicate the extent of retinal and choroidal involvement.

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Immunocompromised patients with systemic Toxoplasma infection presenting with ocular symptoms.

Billing Considerations

Need for interdisciplinary communication regarding patient management and follow-up.

Coding Guidelines

Inclusion Criteria

Use B57.2 When
  • According to the ICD
  • 10 coding guidelines, B57
  • 2 should be used when the clinical documentation specifies Toxoplasma chorioretinitis
  • It is important to include details about the patient's immunocompromised status and any associated systemic conditions

Exclusion Criteria

Do NOT use B57.2 When
  • Exclusion criteria include cases where the infection is not ocular or where another cause of chorioretinitis is documented

Related CPT Codes

92002CPT Code

Ophthalmological examination, new patient.

Clinical Scenario

Used for initial evaluation of a patient presenting with symptoms of chorioretinitis.

Documentation Requirements

Complete ocular examination findings and patient history.

Specialty Considerations

Ophthalmologists should document all relevant findings to support the diagnosis.

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. B57.2 provides a clear distinction for ocular manifestations, which aids in clinical management and research.

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. B57.2 provides a clear distinction for ocular manifestations, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. B57.2 provides a clear distinction for ocular manifestations, which aids in clinical management and research.

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.

How is Toxoplasma chorioretinitis diagnosed?

Diagnosis is typically made through clinical examination, serological testing for Toxoplasma antibodies, and imaging studies such as fundus photography.

What is the treatment for Toxoplasma chorioretinitis?

Treatment usually involves antiparasitic medications such as pyrimethamine and sulfadiazine, often combined with corticosteroids to reduce inflammation.