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B37.9
ICD-10-CM
Candida Albicans Infection

Learn about Candida albicans infection (candidiasis), including clinical documentation, diagnosis codes, and healthcare best practices. This resource provides information on yeast infection symptoms, treatment, and medical coding for Candida albicans, supporting accurate clinical documentation for healthcare professionals. Find details on diagnosing and managing candidiasis effectively.

Also known as

Candidiasis
Yeast Infection

Diagnosis Snapshot

Key Facts
  • Definition : Fungal infection caused by Candida albicans overgrowth.
  • Clinical Signs : Itching, redness, white discharge, skin rash. Can affect mouth, genitals, skin folds.
  • Common Settings : Warm, moist areas. Often associated with antibiotic use, diabetes, weakened immunity.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC B37.9 Coding
B37.0-B37.9

Candidiasis

Infections caused by the yeast Candida, affecting various body sites.

B37.2

Candidiasis of other urogenital sites

Candida infections affecting the genitals or urinary tract.

B37.89

Other candidiasis

Candidiasis affecting sites not specifically classified elsewhere.

A00-B99

Certain infectious and parasitic diseases

Broad category encompassing various infections, including candidiasis.

Code-Specific Guidance

Decision Tree for

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

Is the Candida albicans infection localized?

  • Yes

    Specify infection site.

  • No

    Is it disseminated candidiasis?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Yeast infection of skin, mouth, or genitals.
Overgrowth of normal skin yeast, not usually invasive.
Invasive infection by Candida species, often in immunocompromised.

Documentation Best Practices

Documentation Checklist
  • Document infection site (e.g., oral, skin, vaginal)
  • Record symptoms (e.g., itching, discharge, white patches)
  • Note KOH prep or culture results if performed
  • Document risk factors (e.g., antibiotic use, diabetes)
  • Detail treatment plan (e.g., antifungals, duration)

Coding and Audit Risks

Common Risks
  • Unspecified Site

    Coding Candida albicans infection without specifying the affected site (e.g., oral, skin) leads to coding errors and claim rejections. Use specific ICD-10 codes like B37.x.

  • Clinical Validation

    Lack of proper documentation to support the Candida diagnosis can cause audit issues. CDI specialists should query physicians for clarification to ensure accurate coding.

  • Overcoding Candidiasis

    Coding candidiasis as a primary diagnosis when it is a secondary infection or colonization increases healthcare costs and poses compliance risks. Accurate documentation is crucial.

Mitigation Tips

Best Practices
  • ICD-10 B37.89, proper site documentation for Candida albicans infection.
  • Optimize CDI: Yeast infection vs. Candidiasis. Specify affected area.
  • Ensure antifungal susceptibility testing. Document treatment & response.
  • Prevent cross-contamination: Hand hygiene, sterilize equipment (SNOMED CT).
  • Patient education: Hygiene, medication adherence, follow-up for compliance.

Clinical Decision Support

Checklist
  • Confirm patient symptoms (itching, burning, discharge)
  • Check for white plaques or redness in affected area
  • Microscopic exam or culture for definitive diagnosis
  • Consider patient risk factors (diabetes, antibiotics)

Reimbursement and Quality Metrics

Impact Summary
  • Candida Albicans Infection (Candidiasis, Yeast Infection) reimbursement hinges on accurate ICD-10 coding (B37.x) for optimal claims processing.
  • Coding quality directly impacts Candida infection diagnosis-related group (DRG) assignment and subsequent hospital reimbursement.
  • Timely Candida albicans diagnosis reporting influences infection control metrics and public health surveillance data accuracy.
  • Proper documentation of Candida infection severity and treatment impacts quality reporting and value-based care 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 diagnostic tests for differentiating Candida albicans infection from other similar-presenting conditions in clinical practice?

A: Differentiating Candida albicans infection from conditions like bacterial vaginosis, contact dermatitis, or other fungal infections requires a multifaceted approach. Microscopy with potassium hydroxide (KOH) wet mount is a rapid, cost-effective initial step for visualizing fungal elements. However, culture on Sabouraud dextrose agar remains the gold standard for definitive species identification, which is crucial for guiding targeted antifungal therapy. In complex or recurrent cases, molecular methods like PCR can offer enhanced sensitivity and specificity. Consider implementing a combination of these diagnostic strategies to ensure accurate differentiation and appropriate management. Explore how antifungal susceptibility testing can further personalize treatment plans for challenging Candida albicans infections.

Q: How can I effectively manage recurrent vulvovaginal candidiasis in a patient with underlying risk factors like uncontrolled diabetes or immunosuppression?

A: Managing recurrent vulvovaginal candidiasis (RVVC) in patients with uncontrolled diabetes or immunosuppression necessitates a comprehensive strategy addressing both the infection and underlying predisposing factors. Optimizing glycemic control in diabetic patients and adjusting immunosuppressive regimens where feasible are crucial first steps. Antifungal treatment, typically with longer courses or maintenance therapy, is often required. Fluconazole, itraconazole, or topical agents can be effective, but antifungal susceptibility testing should guide selection. Explore how prophylactic antifungal strategies, alongside lifestyle modifications like minimizing antibiotic use and optimizing hygiene, can reduce recurrence rates in these complex cases. Learn more about the emerging role of immunotherapeutic approaches in managing RVVC in immunocompromised individuals.

Quick Tips

Practical Coding Tips
  • Code B37.89 for unspecified Candidiasis
  • Code B37.2 for oral Candidiasis
  • Code B37.3 for vulvovaginal Candidiasis
  • Consider site-specific codes
  • Document clinical findings clearly

Documentation Templates

Patient presents with symptoms suggestive of Candida albicans infection (candidiasis, yeast infection).  Presenting complaint includes [specific patient complaint, e.g., oral thrush, vaginal itching, diaper rash, skin rash].  On physical examination, [describe observed clinical findings, e.g.,  white plaques on the tongue and buccal mucosa, erythematous vulvovaginal area with thick white discharge, erythematous skin folds with satellite lesions].  Differential diagnosis includes [list potential alternative diagnoses, e.g., bacterial vaginosis, contact dermatitis, seborrheic dermatitis].  Diagnostic testing may include [list relevant tests, e.g., KOH prep, fungal culture, wet mount microscopy].  Based on clinical presentation and [state basis for diagnosis, e.g., positive KOH showing pseudohyphae and budding yeast, positive culture for Candida albicans], the diagnosis of Candida albicans infection is established.  Treatment plan includes [detail prescribed treatment, e.g., topical antifungal cream such as clotrimazole or miconazole, oral fluconazole, nystatin suspension].  Patient education provided regarding [relevant patient education topics, e.g., medication administration, hygiene practices, risk factors for recurrence].  Follow-up scheduled in [timeframe] to assess treatment response and address any ongoing symptoms.  ICD-10 code [relevant ICD-10 code, e.g., B37.89] assigned.  This documentation supports medical necessity for billed procedures and prescribed medications.