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v1.0.0
ICD-10 Guide
ICD-10 CodesB58.9

B58.9

Toxoplasmosis, unspecified

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

Code Description

ICD-10 B58.9 is a billable code used to indicate a diagnosis of toxoplasmosis, unspecified.

Key Diagnostic Point:

Toxoplasmosis is an infection caused by the protozoan parasite Toxoplasma gondii, which is commonly found in cat feces, contaminated food, and water. The infection can be asymptomatic in healthy individuals but can lead to severe complications in immunocompromised patients, such as those with HIV/AIDS or undergoing chemotherapy. In pregnant women, it poses a risk of congenital transmission, potentially leading to serious fetal complications. Symptoms may include flu-like signs, lymphadenopathy, and ocular issues. Diagnosis is typically made through serological testing for Toxoplasma antibodies or PCR testing. Treatment often involves the use of pyrimethamine and sulfadiazine, along with folinic acid to mitigate side effects. In cases of ocular toxoplasmosis, specific therapies may be required. The unspecified nature of this code indicates that the clinical details regarding the severity or specific manifestations of the infection are not documented, which can complicate treatment and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and severity of toxoplasmosis.
  • Need for serological testing and interpretation of results.
  • Differentiation between acute and chronic infections.
  • Potential for co-infections in immunocompromised patients.

Audit Risk Factors

  • Inadequate documentation of symptoms or clinical findings.
  • Failure to specify immunocompromised status when applicable.
  • Lack of follow-up documentation for treatment efficacy.
  • Misclassification of acute versus chronic toxoplasmosis.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed clinical history, laboratory results, and treatment plans.

Common Clinical Scenarios

Management of immunocompromised patients with suspected toxoplasmosis.

Billing Considerations

Need for clear documentation of serological testing and treatment response.

Obstetrics

Documentation Requirements

Pregnancy status, serological testing results, and fetal monitoring.

Common Clinical Scenarios

Screening and management of pregnant women with potential exposure to Toxoplasma.

Billing Considerations

Documentation of counseling regarding risks to the fetus and follow-up care.

Coding Guidelines

Inclusion Criteria

Use B58.9 When
  • According to ICD
  • 10 guidelines, B58
  • 9 is used when the specific manifestations of toxoplasmosis are not documented
  • Coders should ensure that the diagnosis is supported by clinical documentation and that any relevant laboratory tests are noted

Exclusion Criteria

Do NOT use B58.9 When
No specific exclusions found.

Related CPT Codes

86777CPT Code

Toxoplasma antibody test

Clinical Scenario

Used to confirm diagnosis in suspected cases of toxoplasmosis.

Documentation Requirements

Document the reason for testing and results.

Specialty Considerations

Infectious disease specialists should ensure comprehensive testing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of toxoplasmosis, enabling better tracking of the disease and its complications. B58.9 serves as a catch-all for unspecified cases, but coders must strive for specificity when possible.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of toxoplasmosis, enabling better tracking of the disease and its complications. B58.9 serves as a catch-all for unspecified cases, but coders must strive for specificity when possible.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of toxoplasmosis, enabling better tracking of the disease and its complications. B58.9 serves as a catch-all for unspecified cases, but coders must strive for specificity when possible.

Resources

Clinical References

  • •
    CDC Toxoplasmosis Information

Coding & Billing References

  • •
    CDC Toxoplasmosis Information

Frequently Asked Questions

What are the common symptoms of toxoplasmosis?

Common symptoms include flu-like signs such as fever, muscle aches, and fatigue. In severe cases, especially in immunocompromised individuals, it can lead to neurological symptoms or ocular issues.

How is toxoplasmosis diagnosed?

Diagnosis is typically made through serological testing for Toxoplasma antibodies, with PCR testing available for acute cases. Imaging studies may be used in cases of suspected central nervous system involvement.