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ICD-10 Guide
ICD-10 CodesB58.09

B58.09

Other toxoplasma oculopathy

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

Code Description

ICD-10 B58.09 is a billable code used to indicate a diagnosis of other toxoplasma oculopathy.

Key Diagnostic Point:

Toxoplasma oculopathy is an ocular manifestation of Toxoplasma gondii infection, a protozoan parasite that can cause significant visual impairment. This condition typically arises in individuals with compromised immune systems, such as those with HIV/AIDS, but can also occur in immunocompetent individuals. The infection can lead to retinochoroiditis, characterized by inflammation of the retina and choroid, resulting in symptoms such as blurred vision, floaters, and scotomas. Diagnosis is often made through clinical examination, supported by serological tests for Toxoplasma antibodies and imaging studies like optical coherence tomography (OCT) or fundus photography. Treatment usually involves the use of antiparasitic medications such as pyrimethamine and sulfadiazine, often in conjunction with corticosteroids to manage inflammation. Early diagnosis and treatment are crucial to prevent irreversible vision loss. In cases where the oculopathy is not typical or presents with atypical features, the code B58.09 is used to specify 'other' forms of toxoplasma oculopathy, which may require further investigation and tailored management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from other ocular infections
  • Need for comprehensive patient history and serological testing
  • Variability in clinical presentation
  • Potential for co-infection with other pathogens

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to document serological test results
  • Misclassification of the type of oculopathy
  • Lack of evidence for immunocompromised status

Specialty Focus

Medical Specialties

Ophthalmology

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with blurred vision, floaters, or visual field defects.

Billing Considerations

Ensure documentation reflects the severity and duration of symptoms, as well as any prior treatments.

Infectious Disease

Documentation Requirements

Comprehensive patient history, including immunocompromised status and serological test results.

Common Clinical Scenarios

Patients with HIV/AIDS presenting with ocular symptoms.

Billing Considerations

Document any co-infections and the rationale for treatment choices.

Coding Guidelines

Inclusion Criteria

Use B58.09 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the condition's specifics
  • Include any relevant laboratory results and imaging studies to support the diagnosis

Exclusion Criteria

Do NOT use B58.09 When
No specific exclusions found.

Related CPT Codes

92014CPT Code

Ophthalmological examination, comprehensive, established patient

Clinical Scenario

Used for follow-up examinations of patients diagnosed with toxoplasma oculopathy.

Documentation Requirements

Document visual acuity, fundoscopic findings, and any changes in treatment.

Specialty Considerations

Ophthalmologists should ensure thorough documentation of all 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 conditions like toxoplasma oculopathy, improving the accuracy of patient records and treatment plans.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like toxoplasma oculopathy, improving the accuracy of patient records and treatment plans.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like toxoplasma oculopathy, improving the accuracy of patient records and treatment plans.

Resources

Clinical References

  • •
    CDC Toxoplasmosis Information

Coding & Billing References

  • •
    CDC Toxoplasmosis Information

Frequently Asked Questions

What is the primary cause of toxoplasma oculopathy?

Toxoplasma oculopathy is primarily caused by the protozoan parasite Toxoplasma gondii, which can lead to inflammation of the retina and choroid.