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A04.72
ICD-10-CM
C. diff Colitis

Learn about C. diff Colitis (Clostridioides difficile colitis), also known as C. difficile infection (CDI). This resource provides information on diagnosis, clinical documentation, and medical coding for C. diff Colitis, supporting healthcare professionals in accurate and efficient record keeping. Explore details regarding CDI treatment, symptoms, and prevention to improve patient care and optimize clinical workflows.

Also known as

Clostridioides difficile colitis
C. difficile infection
CDI

Diagnosis Snapshot

Key Facts
  • Definition : Inflammation of the colon caused by the bacteria Clostridioides difficile.
  • Clinical Signs : Watery diarrhea, abdominal pain, fever. Severe cases can lead to toxic megacolon.
  • Common Settings : Hospitals, long-term care facilities, after antibiotic use.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC A04.72 Coding
A04.7

Enterocolitis due to Clostridium difficile

Inflammation of the small and large intestines caused by C. diff.

A04.8

Other specified bacterial intestinal infections

Intestinal infections caused by bacteria other than those specifically listed.

K52.8

Other specified noninfective gastroenteritis and colitis

Gastrointestinal inflammation not caused by infection, specified as other.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the C. diff infection confirmed?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Inflammation of the colon caused by C. diff bacteria.
Inflammation of the colon from an unknown cause.
Antibiotic-associated diarrhea not due to C. diff.

Documentation Best Practices

Documentation Checklist
  • Document C. diff colitis symptoms (diarrhea, abdominal pain)
  • Specify onset and duration of C. diff symptoms
  • Note relevant lab findings (positive C. diff test)
  • Document severity (mild, moderate, severe)
  • Include treatment plan (antibiotics, supportive care)

Coding and Audit Risks

Common Risks
  • Unspecified CDI

    Coding C. diff without specifying if it's initial or recurrent impacts reimbursement and quality metrics. CDI coding guidelines require this distinction.

  • Missed CDI Complications

    Failing to code complications like toxic megacolon or sepsis with CDI understates severity, affecting DRG assignment and quality reporting. Accurate CDI coding is crucial.

  • Incorrect CDI POA

    Inaccurate present on admission (POA) coding for CDI can lead to penalties related to hospital-acquired infections. Proper CDI POA indicator assignment is essential for compliance.

Mitigation Tips

Best Practices
  • Document CDI risk factors: antibiotic use, PPI, hospital stay.
  • Order appropriate C. diff testing: NAAT/PCR, not EIA.
  • Optimize antibiotic prescribing: shortest effective duration.
  • Implement infection control measures: hand hygiene, contact precautions.
  • Ensure accurate CDI coding: ICD-10-CM A04.7, specify if recurrent.

Clinical Decision Support

Checklist
  • Recent antibiotic use? Document type, duration, and indication.
  • 3+ loose stools in 24hrs? Document stool characteristics.
  • Consider C. diff testing: PCR, GDH, or toxin assay. Document rationale.
  • Positive C. diff test? Isolate patient, initiate contact precautions.
  • Document severity: mild, moderate, or severe. Include supportive evidence.

Reimbursement and Quality Metrics

Impact Summary
  • C diff Colitis (CDI) coding accuracy impacts reimbursement for hospital stays and antibiotic treatment.
  • Proper C diff diagnosis coding affects quality metrics like hospital-acquired infection rates and CDI management.
  • Accurate CDI coding is crucial for public health reporting and infection control surveillance.
  • C diff Colitis present on admission (POA) indicator impacts DRG assignment and hospital reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective C. diff colitis treatment strategies for recurrent infections in older adults, considering antibiotic stewardship principles?

A: Recurrent Clostridioides difficile infection (CDI) in older adults presents a significant clinical challenge, often complicated by comorbidities and polypharmacy. Effective treatment requires a multi-faceted approach incorporating antibiotic stewardship principles. For a first recurrence, fidaxomicin or a pulsed tapered vancomycin regimen is recommended. Subsequent recurrences often warrant consideration of fecal microbiota transplantation (FMT), which has shown high success rates in restoring gut microbiota diversity and preventing further CDI episodes. Bezlotoxumab, a monoclonal antibody targeting C. difficile toxin B, can also be considered as adjunctive therapy to reduce recurrence risk. Careful antimicrobial prescribing practices, including minimizing broad-spectrum antibiotic use, are crucial in preventing future infections. Explore how integrating FMT and bezlotoxumab within an antibiotic stewardship program can improve outcomes in recurrent CDI cases. Consider implementing a standardized CDI treatment protocol to ensure consistent and evidence-based management across your practice.

Q: How can I differentiate between C. diff colitis and other causes of infectious diarrhea, such as Campylobacter or Salmonella, based on clinical presentation and diagnostic testing?

A: Differentiating Clostridioides difficile infection (CDI, or C. diff colitis) from other infectious diarrheal illnesses like Campylobacter or Salmonella requires a combination of clinical assessment and laboratory testing. While all can present with diarrhea, CDI is more likely associated with a recent history of antibiotic use, distinct odoriferous stool, and potential complications like pseudomembranous colitis. Campylobacter and Salmonella infections may present with more systemic symptoms like fever and abdominal cramping. Initial diagnostic testing for CDI typically involves a nucleic acid amplification test (NAAT) for C. difficile toxins. Stool cultures can identify Campylobacter and Salmonella species. Imaging studies like abdominal CT scans may be necessary to visualize complications like toxic megacolon in severe CDI. For patients with a negative NAAT but high clinical suspicion for CDI, consider additional testing, such as the glutamate dehydrogenase (GDH) antigen test or cell cytotoxicity assay, to rule out false negatives. Learn more about optimizing diagnostic workflows for infectious diarrhea to enhance clinical decision-making.

Quick Tips

Practical Coding Tips
  • Code C. diff colitis as A04.7
  • Document CDI severity & location
  • Query physician for CDI specifics
  • Consider CDI complications codes
  • Check for CDI-related procedures

Documentation Templates

Patient presents with symptoms consistent with Clostridioides difficile colitis (C. diff Colitis, CDI, C. difficile infection).  Onset of profuse, watery diarrhea was reported as [Date of onset], with an associated frequency of [Number] bowel movements per day.  Stool is described as [Description of stool; e.g., malodorous, loose, containing mucus].  Patient also reports [Presence or absence of abdominal pain/cramping] and [Presence or absence of fever].  Vital signs recorded as temperature [Temperature], heart rate [Heart rate], blood pressure [Blood pressure], and respiratory rate [Respiratory rate].  Patient's medical history includes [Relevant past medical history, including antibiotic use within the last 3 months, recent hospitalization, and known risk factors for CDI].  Physical examination reveals [Relevant physical exam findings, e.g., abdominal tenderness, dehydration].  Differential diagnosis includes infectious colitis, inflammatory bowel disease, and irritable bowel syndrome.  Laboratory testing ordered includes stool studies for C. difficile toxin and PCR.  Given the clinical presentation and risk factors, a presumptive diagnosis of C. difficile colitis is made.  Treatment initiated with [Medication name and dosage; e.g., oral vancomycin 125mg QID].  Patient education provided regarding contact precautions, hygiene measures, and the importance of completing the full course of antibiotics.  Follow-up scheduled in [Timeframe] to assess treatment response and resolution of symptoms.  ICD-10 code A04.7 assigned.  This documentation supports medical necessity for testing and treatment of C. difficile colitis.